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Official Journal of the American Society of Abdominal Surgeons, Inc.

This article originally appeared in the Winter 20011 / Spring 2012 issue of the Journal.

"Keys to the Kingdom:" Ritualism in the Surgical Disciplines

Kai J. Rodning, M.D.
Attending Anesthesiologist
Springhill Medical Center
Mobile, Alabama

Christopher B. Rodning, Ph.D.
Assistant Professor
Department of Anthropology/Archaeology
Tulane University
New Orleans, Louisiana

Soren P. Rodning, D.V.M., M.S., D.A.S.T.
Assistant Professor
Colleges of Veterinary Medicine and Agriculture
Auburn University

Address for correspondence:
Audencio Alanis, M.D.
201 Enterprise Ave
Suite 100
League City, Texas 77573
Tel: (713) 455-5531
Fax: (713) 455-5321


Background: To conceptualize peri-operative patient care as ritualistic and an operation as performance art, foundational and grounded upon the “keys to the kingdom.”

Methods: Citation of the anthropological and surgical literature in the context of the “key” strategies of perioperative care, gleaned from our collective professional experience.

Results: Operative endeavors can be stratified from the perspectives of patient, anesthesiologist, and surgeon into a pre-liminal stage of preparation; a liminal stage of performance; and a post-liminal stage of procession. Application of the “keys to the kingdom” facilitates those transitions.

Conclusions: Optimum peri-operative patient care requires ritualized conduct and strategic application of the “keys to the kingdom,” which gives purpose, direction, justification, and meaning to the entire endeavour. The “keys” provide the context and boundaries of that venture, exceeding the technical elements of any operative procedure, to achieve, maintain, and advance standards, excellence, quality, consistency, and safety.

Brief Summary Statement for the Table of Contents: Optimum peri-operative patient care requires ritualized conduct and strategic application of the “keys to the kingdom,” that are directive, purposeful, justificatory, and meaningful. The “keys” provide the context and boundaries of that venture, exceeding the technical elements of any operative procedure, to achieve, maintain, and advance standards, excellence, quality, consistency, and safety. The intent of such is to maximize patient recovery and minimize patient risk, by application of risk-benefit, cost-benefit, effortyield, and benefit-burden analyses systematically.

“… The world is one living, breathing body, dependent for its health on the billions of cells which comprise it… and each tiny cell is the heart of a man…” Keys of the Kingdom (1941) Archibald Joseph Cronin (1896-1981)


Table 1
Rites of Passage Peri-Operatively.

click to enlarge

A. J. Cronin, Scottish physician and novelist, in his tome entitled, Keys of the Kingdom,1 alluded to the sacred, transcendental, and supernatural domains of human existence. He referred to the gifts of authority, power, and dominion provided to humankind by the Divine. We argue that those attributes are also commensurable with secular endeavors, including ritualism in the surgical disciplines and the operating theater.

The ethnologist Professor Pearl Katz defined rituals (L., rı¯tua¯lis, “relating to [religious] rites”) “as standardized ceremonies in which expressive, symbolic, mystical, sacred, and non-rational behavior predominates over practical, technical, secular, rational, and scientific behavior.”2 Nevertheless, she and other anthropologists2,3 have acknowledged that rational and technical acts may be ritualistic. They also suggested that rituals in both sacred and secular domains, could be investigated and analyzed from multiple perspectives:

  • meaning, structure, and typology of particular symbols;4, 5
  • cognitive processes that occur in relation to symbolism and ritualism, such as belief in the effectiveness of stylized behavior or the establishment of interpersonal boundaries and hierarchies;6
  • movement of participants through rites of passage in space, time, and/or status;7 and
  • as a form of intra- and inter-personal communication.8

Professor L. L. Wall deliberated upon the latter two perspectives and suggested that ritual from an anthropological perspective is “… a form of stylized behavior that serves as a vehicle for the transmission of meaning,”9 purpose, direction, and justification.


The latter analytic perspectives are applicable to the surgical disciplines and the operating theater (Table I and Figure 1). For example, the French sociologist Professor Arnold Van Gennup7 argued that participants in a ritual moved through three stages as they acquired their new status: (1)rite of separation; (2)rite of transition; and (3)rite of incorporation. The rite of separation—the preliminal (L., limen, “threshold”) phase—was a period of preparation. The rite of transition — the liminal phase — was a period of performance and was associated with the greatest danger and uncertainty for the initiate/patient. The rite of incorporation — the post-liminal phase — was a period of procession. Such rites imposed spatial and temporal boundaries — “sacred spaces,” the violation of which incurred harsh sanctions. Wall9 argued that those rites of passage were coextensive with the rituals of the surgical disciplines and, more specifically, with performance of procedures in the operating theater (L., theatrum, Gk., theatron, “to gaze at,” “contemplate,” “view,” “watch,” “see”). Permit us to rehearse those perspectives.


Pre-Liminal Phase — Preparation: During the pre-operative or “pre-liminal phase” of the operative ritual, a patient is isolated, disrobed, purged, cleansed, and restricted. A patient becomes relatively passive, humble, compliant, obedient, frightened, and powerless. By contrast, the anesthesiologist and surgeon become active, commanding, and empowered as they don appropriate attire and attend to ablutions prior to entering the “sacred space” of the operating theater to don sterile gown and gloves. Only the initiated are permitted to enter that arena and only under sterile conditions. Violation of sterility results in harsh recrimination.

Liminal Phase — Performance: The operative or “liminal phase” of the ritual is the most dangerous and during that phase a patient is most vulnerable. A patient is totally dependent upon the anesthesiologist/ anesthetist for sustenance during an operation and the surgeon and assistants for conduct of that operation. The performance (L., performin, “to furnish”) of an operation is highly standardized and stylized, with a specific flow, rhythm, and sequence adapted to a patient’s unique condition, anatomy, and pathology. The surgical team officiates at and conducts that ritual and, as such, an operation is a technical composition and a performance art.

Table II:
Keys to the Kingdom.

click to enlarge

Post-Liminal Phase — Procession: The post-operative or “post-liminal” phase of this tripartite ritual begins a procession toward recovery and normality. A patient is awakened from anesthesia and with time resumes activities of daily living, reunites with family and friends, and ideally recovers health and wholeness. The 6 “KEYS TO THE KINGDOM:”RITUALISM IN THE SURGICAL DISCIPLINES Table I: Rites of Passage Peri-Operatively. Rite Phase Threshold Boundary Meaning separation pre-operative pre-liminal old preparation transition operative liminal transitional performance incorporation post-operative post-liminal new procession anesthesiologist and surgeon, having performed highly technical endeavors, also return to the mundane of everyday existence, activities, and demands.

Operative procedures thus consist of a complement of complex symbols relating to health and well-being of a patient that possess substantive ritualistic meaning (Ofr., meien, L. medianus, “that which is halfway between extremes,” “signification.” “teleological”).

Wholeness: The concept of wholeness, as derived from Occidental intellectual, philosophical, and secular traditions11-16 and from cultural and linguistic patterns of sacred Judeo- Christocentric creeds, is germane. In the orthodox use of that term, the individual self was never seen without an awareness of the community of which he/she was an integral part. All understood that people found completeness, curing, healing, totality, and wholeness within a covenantal relationship, and that caring, community, and harmony derived from that covenant. Throughout the societies of antiquity, health, health care, and related moral and ethical concerns were a function of covenants.

When human beings “belong together,” they also share a common life, common responsibility, and common will. The personal community of the family was only one expression of the common life and wholeness pervading ancient societies. In its antecedent forms, that unity was a result of “blood”—either of kin or of covenant. As it appeared in the ancient Hebrew, “covenant” was something that was “cut,” and its ratification involved the shedding of blood—perspectival of the operative disciplines. As a consequence of a covenant, individuals became a unity of self, system, and society that possessed one goal—healing, wellness, and wholeness of the total self. Use of the word religion in its generic sense is apt in this context, as it is etymologically derived from the Latin, religa¯re, denoting “to bind together.” Optimization of outcomes and restoration and improvement of function remain germane contemporaneously.


Keys to the Kingdom (Table II): As alluded to previously, the keys of the kingdom include the universals of power, dominion, and authority. However, the keys to the kingdom require the particulars of what the preeminent physician Sir William Osler17 referred to as:

  • “the art of detachment”— objectivity, disinterest, strategic;
  • “the virtue of method”— algorithms, guidelines, checklists, pathways;
  • “the quality of thoroughness”— analyticity, systematize; and
  • “the grace of humility”— contingency, ambiguity, uncertainty.

Again, permit us to amplify and intensify those perspectives.

A. B. C. (Airway-Breathing-Circulation): The ensurance of perfusion and oxygenation of organs and tissues.

Interrogation: The elucidation of information germane to the patient’s current status; past medical/surgical, familial, and social histories; and review of symptoms/signs by organ/system.

Physical Examination/Regional Anatomy: The cognitive “visualization” of surface topographic and regional anatomic relationships.

Stratification/Categorization of Clinical Conditions Temporally: The differentiation of emergent (immediate), urgent (within 24 hours), and elective (when convenient) diagnostic evaluations and therapeutic interventions.

Figure I:
Venn diagram.

click to enlarge
Figure II:

click to enlarge

Prioritization: The prioritization of resuscitation, diagnostic evaluation, and more definitive therapeutic intervention applies. In the emergent setting, with a surgeon and/or anesthesiologist in command and giving purpose, direction, justification, and meaning to the entire endeavour, those maneuvers may need to and can be performed concurrently.

Localization: The differentiation of local, regional, and systematic manifestations of a patient’s condition will influence prioritization of management and care (vide supra). Subjective — Objective — Assessment — Plan (S.O.A.P.): A schema of documentation that incorporates dimensions of information, comparative parameters, and probabilities, to identify the causality of organ/system dysfunction/failure.

Universal Precautions: Gowns, gloves, headwear, facemasks, eye protection, topical aseptic/anti-septic techniques, and draping are essential to protect both patient and health care providers.

Informed Consent: Semantically, legally, and ethically, informed consent implies voluntary written permission by a mentally competent patient to undergo an elective or urgent medical treatment or operative procedure after he/she has been given the opportunity to be apprised of the techniques, indications, risks, benefits, and alternatives.18 The concept of “presumed consent” applies in the emergent life threatening setting (Good Samaritan).

Checklists and Time Out: Verbal and written transmission of accurate, precise, pertinent, and specific information to maximize patient benefit and to minimize patient risk, has been adopted and adapted from the aviation industry and applied to the surgical disciplines. 19-22 The intention of checklists and a time out is to compensate for limitations of human memory and attention and to foster consistency and completeness of a task.

Delineate Pathology and Stage of Dissemination of Disease: Exposure and retraction of soft tissues and viscera; isolation and protection from contamination; and tamponade of hemorrhage are performed prior to dissection. Proceeding from the known to the unknown, from the normal to abnormal, from the superficial to deep, with tissue under tension, are rational and effective strategies of dissection. Arrest of hemorrhage, arrest of contamination, and proximal and distal control are imperatives. Damage control by packing and temporary closure with planned re-exploration within 24-72 hours has emerged as a rational strategy for patients with unrelenting hemodynamic instability, hypothermia, coagulopathy, and sepsis.23

Restoration: The restoration of arteriovenous circulation, alimentary and genitourinary tract continuity, and skeletal and soft tissue integrity, concurrently or staged, requires tensionless coaptation.

Simplify: Ockham’s (Occam’s) Razor is a meta-theoretical principle that “entities must not be multiplied beyond necessity” (L., entia non sunt multiplicanda praeter necessitatem).24 It is attributed to William of Ockham (1288-1348, aka Willem, Wilhelm, Occam, Hockham) native to Ockham, Surrey, England (Figure 2). He was a logician, philosopher, theologian, and Roman Catholic Franciscan friar, who concluded that the simplest solution was usually correct. The Razor may be alternatively phrased as “plurality should not be posited without necessity” (L., pluralitas non est ponenda sine necessitatem). The principle is often expressed as lex parsimoniae (L., “law of parsimony,” law of economy, or law of succinctness). When competing hypotheses are equal in other respects, the principle recommends selection of the hypothesis that introduces the fewest assumptions and postulates the fewest entities, while still sufficiently answering the question. It is in this sense that the Razor is usually understood and which in general, by and large, and for the must part (L., nos epi to poli) applies.


Optimum peri-operative patient care requires ritualized conduct and strategic application of the "keys to the kingdom," that are directive, purposeful, justificatory, and meaningful. The "keys" provide the context and boundaries of that venture, exceeding the technical elements of any operative procedure, to achieve, maintain, and advance standards, excellence, quality, consistency, and safety. The intent of such is to maximize patient recovery and minimize patient risk, by application of risk-benefit, cost-benefit, effort-yield, and benefit-burden analyses systematically.


The authors gratefully acknowledge the superb typing of the manuscript by Ms. Betty J. Morris Pledger, Secretary V, Department of Surgery, College of Medicine, University of South Alabama, Mobile, Alabama.



1. Cronin A J. Keys of the Kingdom. Boston, MA: Little, Brown and Company; 1941.

2. Katz P. Ritual in the operating room. Ethnology, 1981; 20(4):335-350.

3. Katz P. The Scapel’s Edge: The Culture of Surgeons. London, UK: Allyn & Bacon; 1999.

4. Turner V W. The Forest of Symbols. Aspects of Ndembu Ritual. Ithaca, NY: Cornell University Press; 1967.

5. Turner V. The Ritual Process: Structure and Anti- Structure. Chicago, IL: Aldine Publishing Company; 1969.

6. Levi-Strauss C. The Savage Mind. London, UK: Weidenfeld and Nicolson, Ltd; 1966.

7. Van Gennep A. The Rites of Passage. Chicago, IL: University of Chicago Press; 1960.

8. Douglas M. Purity and Danger: An Analysis of Concepts of Pollution and Taboo. London, UK: Routledge & Kegan Paul; 1966.

9. Wall L L. Ritual meaning in surgery. Obstetrics & Gynecology. 1996; 88:633-637.

10. Moynihan B G A. The ritual of a surgical operation. British J Surg. 1920/21; 8:27-35.

11. Schaffner KD. Reductionism and holism in medicine. J Med Phil. 1981; 6:93-235.

12. Russell B. Wisdom of the West. New York, NY: Crescent Books, 1977.

13. Bettmann OL. A Pictorial History of Medicine. Springfield, IL: Charles C. Thomas, 1956.

14. Nouwen HJM. Creative Ministry. Garden City, NY: Image Books, 1971.

15. Marty ME, Vaux KL, eds. Health/Medicine and the Faith Traditions: An Inquiry into Religion and Medicine. Philadelphia, PA: Fortress Press, 1982.

16. D’annay D, Rodning CB. Patient-physician interaction: Healing power of a covenant relationship. Humane Med. 1988; 4(2):107-109.

17. Osler W. Teacher and student. In Osler’s “A Way of Life” and Other Addresses, with Commentary and Annotations. Eds. Hinohara S, Niki H. Durham, NC: Duke University Press, 2001; 109-124.

18. Appelbaum PS. Assessment of patients’ competence to consent to treatment. New Eng J Med. 2007; 357(18): 1834-1840.

19. Healy GB, Barker J, Madonna G. Error reduction through team leadership: Applying aviation’s CRM model to the OR. Bull Amer Coll Surg. 2006; 91(6):10-15.

20. Healy GB, Barker J, Madonna G. Error reduction through team leadership: Seven principles of CRM applied to surgery. Bull Amer Coll Surg. 2006; 91(6):24-26.

21. Healy GB, Barker J, Madonna G. Error reduction through team leadership: The surgeon as leader. Bull Amer Coll Surg. 2006; 91(6):26-29.

22. Gawande A. The Checklist Manifesto: How to Get Things Right. New York, Henry Holt and Company, LLC, 2009.

23. Cirocchi R, Abraha I, Montedori A, Farinella E, Bonacini I, Tagliabue L, Sciannameo F. Damage control surgery for abdominal trauma. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007438. DOI: 10.1002/14651858.CD007438.pub2.

24. Ockham W. Quaestiones et decisions in quattuor libros Sententiarum Petri Lombardi. Lugduni Batavorum, Lyon, France, 1495; i,dist.27,qu2,k.

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Table I: Rites of Passage Peri-Operatively.

Table II: Keys to the Kingdom.

Figure 1: Venn diagram.

Figure II:
Image of William of Ockham, Venerabilis Inceptor (L., "worthy beginner") and Doctor Invincibilis (L., "unconquerable teacher"), stained glass window, All Saintsí Church, Ockham, Surrey, England (In the public domain under terms of the GNU Free Documentation License).