Textbook of Surgery

Julian A. Smith, Andrew H. Kaye, Christopher Christophi, Wendy A. Brown, Julian A. Smith, Andrew H. Kaye, Christopher Christophi, Wendy A. Brown

• Publisher: Wiley-Blackwell
• Year: 2020
• ISBN:
  9781119468165
• Edition: 4
• Topic: Medicina
• Subtopic: Cirugía y medicina quirúrgica

Textbook of Surgery is a core book for medical and surgical students providing a comprehensive overview of general and speciality surgery. Each topic is written by an expert in the field.

The book focuses on the principles and techniques of surgical management of common diseases. Great emphasis is placed on problem-solving to guide students and junior doctors through their surgical training.

Section 1
Principles of Surgery

1
Preoperative management

Julian A. Smith

Department of Surgery (School of Clinical Sciences at Monash Health), Monash University and Department of Cardiothoracic Surgery, Monash Health, Clayton, Victoria, Australia

Introduction

This chapter covers care of the patient from the time the patient is considered for surgery through to immediately prior to operation and deals with important generic issues relating to the care of all surgical patients. Whilst individual procedures each have unique aspects to them, a sound working understanding of the common issues involved in preoperative care is critical to good patient outcomes. The important elements of preoperative management are as follows.

• History taking: the present surgical condition and a general medical review.
• Physical examination: the present surgical condition and a general examination.
• Reviewing available diagnostic investigations.
• Ordering further diagnostic and screening investigations.
• Investigating and managing known or discovered medical conditions.
• Obtaining informed consent.
• Scheduling the operation and any special preparations (e.g. equipment required).
• Requesting an anaesthetic review.
• Marking the operative site/side.
• Prescribing any ongoing medications and prophylaxis against surgical site infection and deep venous thrombosis.
• Planning postoperative recovery and possibly rehabilitation.

Informed consent

Although often thought of in a purely medico‐legal way, the process of ensuring that a patient is informed about the procedure they are about to undergo is a fundamental part of good‐quality patient care. Informed consent is far more than the act of placing a signature on a form. That signature in itself is only meaningful if the patient has been through a reasonable process that has left them in a position to make an informed decision.

There has been much written around issues of informed consent, and the medico‐legal climate has changed substantially in the past decade. It is important for any doctor to have an understanding of what is currently understood by informed consent. Although the legal systems in individual jurisdictions may differ with respect to medical negligence, the standards around what constitutes informed consent are very similar.

Until relatively recently, the standard applied to deciding whether the patient was given adequate and appropriate information with which to make a decision was the so‐called Bolam test – practitioners are not negligent if they act in accordance with practice accepted by a reasonable body of medical opinion. Recent case law from both Australia and overseas has seen a move away from that position. Although this area is complex, the general opinion is that a doctor has a duty to disclose to a patient any material risks. A risk is said to be material if ‘in the circumstances of that particular case, a reasonable person in the patient’s position, if warned of the risk would be likely to attach significance to it or the medical practitioner is, or should reasonably be aware that the particular patient, if warned of the risk would attach significance to it’. It is important that this standard relates to what a person in the patient’s position would do and not just any reasonable person.

Important factors when considering the kinds of information to disclose to patients include the following.

• The nature of the potential risks: more common and more serious risks require disclosure.
• The nature of the proposed procedure: complex interventions require more information as do procedures when the patient has no symptoms or illness.
• The patient’s desire for information: patients who ask questions make known their desire for information and they should be told.
• The temperament and health of the patient: anxious patients and patients with health problems or other relevant circumstances that make a risk more important for them may need more information.
• The general surrounding circumstances: the information required for elective procedures might be different from that required in those conducted emergently.

Verbal discussions concerning the therapeutic options, potential benefits and risks along with common complications are often supplemented with procedure‐specific patient explanatory brochures. These provide a straightforward illustrated account for the patient and their relatives to consider and may be a source of clarification and/or further questions about the proposed operation.

What does this mean for a medical practitioner? Firstly, you must have an understanding of the legal framework and standards. Secondly, you must document how appropriate information was given to patients – always write it down. If discussion points are not documented, it may be argued that they never occurred. On this point, whilst explanatory brochures can be a very useful addition to the process of informed consent they do not remove the need to undertake open conversations with the patient.

Doctors often see the process of obtaining informed consent as difficult and complex, and this view is leant support by changing standards. However, the principles are relatively clear and not only benefit patients but their doctors as well. A fully informed patient is much more likely to adapt to the demands of a surgical intervention, and should a complication occur, they and their relatives almost invariably accept such misfortune far more readily.

Preoperative assessment

The appropriate assessment of patients prior to surgery to identify coexisting medical problems and to plan perioperative care is of increasing importance. Modern trends towards the increasing use of day‐of‐surgery admission even for major procedures have increased the need for careful and systematic preoperative assessment, much of which occurs in a pre‐admission clinic (PAC).

The goals of preoperative assessment are:

• To identify important medical issues in order to
  • optimise their treatment
  • inform the patient of additional risks associated with surgery
  • ensure care is provided in an appropriate environment.
• To identify important social issues which may have a bearing on the planned procedure and the recovery period.
• To familiarise the patient with the planned procedure and the hospital processes.

Clearly the preoperative evaluation should include a careful history and physical examination, together with structured questions related to the planned procedure. Simple questions related to exercise tolerance (such as ‘Can you climb a flight of stairs without being short of breath?’) will often yield as much useful information as complex tests of cardiorespiratory reserve. The clinical evaluation will be coupled with a number of blood and radiological tests. There is considerable debate as to the value of many of the routine tests performed, and each hospital will have its own protocol for such evaluations.

Common patient observations, investigations and screening tests prior to surgery include:

• vital signs (blood pressure, pulse rate, respiratory rate, temperature) and pulse oximetry
• body weight
• urinalysis
• full blood examination and platelet count
• urea and electrolytes, blood sugar, tests of liver function
• blood grouping and screen for irregular antibodies (‘group and hold’)
• tests of coagulation, i.e. international normalised ratio (INR) ...