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Principles of Preoperative and Operative Surgery

By Surajit Sasmal

PREOPERATIVE PREPARATION OF THE PATIENT
• Assessment of patient before surgery is mandatory. • Lack of preoperative assessment increases risks associated with anaesthetics and surgery

Goals of preoperative preparation
• Assess fitness for anaesthesia and surgery by detailed history, physical exam., lab. investigations. • Control of medical conditions before elective surgery • Plan anaesthetic technique

urea and creatinine • CXR • ECG .Preoperative investigations ROUTINE TEST: • CBC & platelets • Sugar .

OTHERS INVESTIGATIONS • Electrolytes (Na+. APTT . K+) • LFT • AMYLASE • PT.

SYSTEMS APPROACH TO PREOPERATIVE EVALUATION Cardiovascular disease contributes to perioperative mortality for noncardiac surgery significantly .

Computation of the Cardiac Risk Index Criteria History Age > 70 yr Myocardial infarction < 6 mo Physical examination S3 gallop or jugular venous distention Aortic valvular stenosis Points 5 10 11 3 .

or aortic operation 3 Emergency operation 4 .0 mg/dL 3 Abnormal SGOT or chronic liver disease Bedridden Operation Intraperitoneal. intrathoracic.• General status PO2 < 60 or PCO2 > 50 K < 3.0 or HCO3 < 20 mEq/L BUN > 50 or creatinine > 3.

9% risk of serious cardiac event or death • Class II (6 to 12 points) .1% risk • Class III (13 to 25 points) .16.0.7.63.Preoperative cardiac risk • Class I (0 to 5 points) .0% risk • Class IV (>26 points) .6% risk .

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• Any patient can be evaluated as a surgical candidate after an acute MI (within 7 days of evaluation). or a recent MI between ( 7 and 30 days of evaluation) • General recommendations are to wait 4 to 6 weeks after MI to perform elective surgery. .

• Perioperative risk for cardiovascular morbidity and mortality decreased receiving ß blockade in the perioperative period versus those receiving placebo.• Improvements in postoperative care centered on decreasing the adrenergic surge associated with surgery and halting platelet activation and microvascular thrombosis. .

• use of aspirin in the immediate postoperative period decreases morbidity and mortality in the cardiac surgery .

• Thoracic and upper abdominal resection cases. and for major abdominal and thoracic cases in patients who are older than 60 years of age.have significant underlying .Pulmonary • Preoperative evaluation of pulmonary function necessary for either thoracic or general surgical procedures. for thoracic procedures requiring single-lung ventilation.

8 L/second. or 30% of predicted.• Necessary tests include the forced expiratory volume at 1 second (FEV1).Adults with an FEV1 of less than 0. have a high risk of complications and postoperative pulmonary insufficiency . and the diffusing capacity of carbon monoxide. the forced vital capacity.

and metabolic derangements secondary to renal dysfunction should be the goal of preoperative evaluation of these patients. The identification of cardiovascular. .Renal • Approximately 5% of the adult population have some degree of renal dysfunction. circulatory. hematologic. which can affect the physiology of multiorgan systems and cause additional morbidity • In the perioperative period.

serum chemistry panel. a chest radiograph may be helpful.• Diagnostic testing for patients with renal dysfunction should include electrocardiogram (ECG). If physical examination findings are suggestive of heart failure. • Urinalysis and urinary electrolyte studies not helpful in the setting of established renal . and • complete blood count (CBC).

anemia. if not treated with erythropoietin. and exertional angina. the bleeding time be evaluated . low exercise tolerance. require preoperative transfusion in the setting of acute operative blood loss. .• Anemia range from mild and asymptomatic to that associated with fatigue. • As the platelet dysfunction of uremia often qualitative .

•Pharmacologic manipulation of hyperkalemia. replacement of calcium for symptomatic hypocalcemia. and the use of phosphate-binding antacids for hyperphosphatemia required .•The patient with end-stage renal disease requires attention in perioperative period.

This can be administered in intravenous (IV) fluid as 1 to 2 ampules in 5% dextrose solution. to optimize their volume status and . • Hyponatremia is treated with volume restriction.• Sodium bicarbonate is used in the setting of metabolic acidosis when serum bicarbonate levels are below 15 mEq/L. • Patients with chronic end-stage renal disease should undergo dialysis prior to surgery. although dialysis is often required within the perioperative period for control of volume and electrolyte abnormalities.

Jaundice and scleral icterus evident with serum bilirubin >3 mg/dL. . caput medusae. and clubbing • Abdominal examination may reveal distention. • Encephalopathy or asterixis . • Skin changes include spider angiomas. • Muscle wasting or cachexia .Hepatobiliary • Evidence of hepatic dysfunction seen on physical examination. palmar erythema. evidence of fluid shift. and hepatomegaly.

• Laboratory evidence of chronic hepatitis or clinical findings consistent with cirrhosis investigated with tests of hepatic synthetic function. and . notably serum albumin. and C. prothrombin. B. Alcoholic hepatitis i suggesting by lower transaminase levels and an AST/ALT ratio > 2.Hepatobiliary • The patient with liver dysfunction should have standard hepatocellular enzyme determination • Coagulation profile should be done. • serologic testing for hepatitis A.

Diuretics 3.Fluid restriction 2.ing factors Coagulopathy Target PT no more than 2 sec above normal 1.3.coagulopathy and proceed to surgery Child’s C: postpone until class improved or cancel surgery 1. Antibiotic prophylaxis 5. No routine preop.Lactulose 2. Ascites 1. K 2.paracentesi s . Biliary drainage 6. fluid management 2. Pre op. Coagulation parameter Encephalopathy 1.FFP 3. Lactulose 4.vit.Cryo ppt.Acute hepati tis Patient with liver disease facing surgery Obstru ctive jaundic e Postpone elective surgery Surge ry safe Chronic hepatiti s Cirrhosis Child’s A&B:treat ascites.Avoid ppt. No dopamine/mannitol 3.

8–3.Child-Pugh Scoring System Points 1 • Encephalopathy Stage III or IV • Ascites Moderate • Bilirubin (mg/dL) >3 • Albumin (g/L) <2.5 4–6 2 .5 <4 Stage I or II Slight 2–3 2.8 • PT >6 (prolonged sec) 3 None Absent <2 >3.

prolongation of the PT beyond 3 seconds and refractory to correction with vitamin K. and the presence of infection. respectively during abdominal operations . • outcome in these patients are the emergent nature of a procedure. and 76%. B. 31%. .• patients with Child’s classes A. and C cirrhosis had mortality rates of 10%.

hyperthyroidism or hypothyroidism. or adrenal insufficiency is subject to additional physiologic stress during surgery. .Endocrine • Patient of diabetes mellitus.

.• Noninsulin-dependent diabetes should discontinue • long-acting sulfonylureas such as chlorpropamide and glyburide owing to the risk of intraoperative hypoglycemia. a shorter-acting agent or sliding-scale insulin • coverage may be substituted in this period. The use of metformin should be stopped preoperatively .

. the substitution with • lower dosages of intermediate-acting insulins (NPH or Lente) should be made on the morning of operation.• The insulin-dependent diabetic should be told to hold long-acting insulin preparations (Ultralente preparations) on the day of surgery.

During operation. • Patient with diabetes mellitus controlled by diet or oral medication not require insulin perioperatively. • poorer control or on insulin therapy require preoperative dosing and both glucose and insulin infusion during surgery. • Adequate hydration .• These patients should be scheduled for early morning • operation. a standard 5% or 10% dextrose infusion is used with short-acting insulin or insulin drip to maintain glycemic control. when feasible.

• Usual doses of ß blockers or digoxin to be continued. . combination of adrenergic blockers and glucocorticoids required. • In urgent surgery in a thyrotoxic patient at risk for thyroid storm.• The patient with hyperthyroidism on antithyroid medication to continue this regimen on the day of surgery.

. • A low-dose ACTH stimulation test demonstrate abnormal response to adrenal stimulation and suggest the need for perioperative steroid supplementation.Patients who have taken more than 5 mg of prednisone (or equivalent) per day for more than 2 weeks within the past year considered at risk undergoing major surgery. • The amount of steroid administered and duration of treatment are titrated to the anticipated degree of perioperative stress.

• Major operations covered with 100 to 150 mg of hydrocortisone equivalent for 2 to 3 days. . • Moderate operations require 50 to 75 mg of hydrocortisone equivalent for 1 or 2 days.• Recent guidelines suggest titrating the dosage of glucocorticoid replacement to the degree of surgical stress.

. • One to two weeks is usually required to achieve adequate therapeutic effect by a blockade. or selective a1 agents such as prazosin. • this can be accomplished with either a nonselective agent such as phenoxybenzamine.• Patients with pheochromocytoma require preoperative pharmacologic management to prevent intraoperative hypertensive crises or hypotension leading to cardiovascular collapse. • The state of catecholamine excess associated with pheochromocytoma should be controlled by a combination of a-adrenergic and ßadrenergic blockade prior to surgery.

• red blood cell transfusion or the use of synthetic erythropoetin or CSF based on the degree of dysfunction and other patient risk factors. .optimize immunologic function prior to operation and to minimize the risks of infection and wound breakdown.Immunology The goal .

When taken within 3 days of surgery. • Steroids reduce the degree of wound inflammation. and collagen synthesis . epithelialization.Immunology • antibiotic prophylaxis • Immunocompromised patients at risk of wound complications. especially if on exogenous steroid therapy.

hematologic • Anemia most common laboratory abnormality in preoperative patients. • patients with normovolemic anemia without cardiac risk or anticipated blood loss managed safely without transfusion. . many healthy patients tolerating hemoglobin levels of 6 or 7g/dl.

transfusion dictated by clinical circumstance.transfusion rarely Guidelines for Red Blood Cell Transfusion for Acute Blood Loss .transfusion usually required. 6–10 g/dL. >10 g/dL.• Evaluate risk of ischemia. • < 30% rapid volume loss not require transfusion in previously healthy individual. • Measure hemoglobin concentration: < 6 g/dL.

• O2 extraction ratio > 50%. suggest that transfusion Guidelines for Red Blood Cell Transfusion for Acute Blood Loss .• Measure vital signs/tissue oxygenation when hemoglobin is 6 to 10 g/dL and extent of blood loss is unknown. VO2 decreased. • Tachycardia and hypotension refractory to volume suggest the need for transfusion.

drug held for several days preoperatively to allow INR to fall to the range of 1.5 or less. .• Patients receiving anticoagulation therapy require preoperative reversal of the anticoagulant effect. • patients taking warfarin.

Recommendations for Perioperative Anticoagulation in Patients Taking Oral Anticoagulants Indication Preoperative Postoperative Acute venous thromboembolism Month 1 Months 2 and 3 Recurrent venous thromboembolism Acute arterial embolism Month 1 Mechanical heart valve Nonvalvular atrial fibrillation IV heparin No change No change IV heparin SC heparin SC heparin IV heparin No change No change IV heparin IV heparin SC heparin .

4 cal PE (%) 0.4 .2 l PE (%) n Strategy Low Minor surgery in patients < 40 yr with no additional risk factors 0. ES or IPC Moderate Minor surgery in patients with additional risk factors: nonmajor surgery in patients aged 40–60 yr with no additional risk factors. major surgery in patients < 40 yr with no 1020 2-4 1-2 0.10.00 2 No specific measures Aggressive mobilizatio n LDUH q 12 hr.Levels of Thromboembolism Risk in Surgical Patients Without Prophylaxis and Successful Prevention Strategies Level of Definition of Risk Level Cal Proxi Clini Fata Preventio Risk f DV T (%) 2 mal DVT (%) 0. LMWH.

cancer. hip or knee arthroplasty. oral anticoag ulants.25 LMWH. major surgery in patients > 40 yr or with additional risk factors Major surgery in patients > 40 yr plus prior VTE. LMWH or IPC Highest 4080 1020 4-10 0. or molecular hypercoagulable state. hip fracture surgery.41 LDUH q 8 hr.Levels of Thromboembolism Risk in Surgical PatientsWithout Prophylaxis and Successful Prevention Strategies Level of Definition of Risk Calf Pro Clinica Fata Prevent Risk Level DVT xim l (%) al PE (%) DVT (%) 2040 4-8 2-4 l PE (%) ion Strateg y High Nonmajor surgery in patients > 60 yr or with additional risk factors. 0. IPC/ES + LDUH/L MWH or ADH .

ADDITIONAL PREOPERATIVE CONSIDERATIONS • Age • Older adults comprise a disproportionate percentage of surgical patients .

Nutritional Status Patients with severe malnutrition (as defined by a combination of weight loss. or prognostic indices) benefitted from preoperative parenteral nutrition . visceral protein indicators.

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PREOPERATIVE checklist • Informed consent • Preoperative orders • The patient should receive written instructions regarding time of surgery and management of special perioperative issues .

. • exception Indwelling prosthesis .Antibiotic Prophylaxis • Prophylactic antibiotics generally not required for clean (class I) cases.  with three or more concomitant diagnoses  those whose operations are abdominal or longer than 2 hours.

• class II procedures benefit from a single dose of appropriate antibiotic administered prior to skin incision. gastroduodenal) cases. . pancreatic. • For abdominal (hepatobiliary. cefazolin is generally used.

• Contaminated(class III) cases require mechanical preparation or parenteral antibiotics with both aerobic and anaerobic activity. • Routine antibiotic prophylaxis in laparoscopic cholecystectomy questionable • except in cases of prosthetic graft (i.e., mesh) placement, such as

-- National Research Council Classification of Operative Wound
Clean (class I)  Nontraumatic

 No inflammation

 No break in technique

Clean-contaminated (classII)
• Gastrointestinal or respiratory tract entered without significant spillage

Contaminated (class III) • Major break in technique Gross spillage from gastrointestinal tract Traumatic wound. fresh Entrance of genitourinary or biliary tracts in presence of infected urine or bile .

Dirty and infected (class IV)  Acute bacterial inflammation encountered. foreign bodies. fecal contamination. or delayed treatment. or from dirty . or all of these. without pus  Transection of “clean” tissue for the purpose of surgical access to a collection of pus  Traumatic wound with retained devitalized tissue.

May increase post op.Preop. Difficile • Removal of bulk fecal material increase anastomotic / infectious complication . infection with Cl. Mechanical bowel cleansing • Oral antibiotic – not beneficial.

• Drugs affecting platelet function held for variable periods: aspirin and clopidogrel held for 7 to 10 days. whereas NSAIDs should be held between 1 day .3 days depending .Review of Medication • cardiovascular morbidity associated with the perioperative discontinuation of ß-blockers and rebound hypertension with abrupt cessation of the antihypertensive clonidine.

• Estrogen use has been associated with an increased risk of thromboembolism held for a period of 4 weeks preoperatively .

Preop. Fasting • Standard order.‘NPO past midnight’ for preop. Carbohydrate supllementation safe and improve patient’s response to perioperative . clean fluid for 2 hrs • Pre op. Patients based on theory of decrease volume and acidity of stomach content • ASA recommend adults stop intake of solid for at least 6 hrs.

Histamine-1 (H1 ) blockade with diphenhydramine 50 mg IV or .3 to 0.5 mL of 1:1000 subcutaneously. this is given IV and repeated at 5. as needed. • When suspected. in severe anaphylaxis. the offending agent should be discontinued and the patient given epinephrine 0.POTENTIAL CAUSES OF INTRAOPERATIVE INSTABILITY • Anaphylaxis/Latex Allergy • Intraoperative anaphylactic reactions occur one in every 4500 surgical procedures and carry a risk of mortality of 3% to 6%.to 10-minute intervals.

• MH treated by discontinuation of inhalational anesthetic agents and succinylcholine.Hyperthermia • The incidence of malignant hyperthermia (MH) is higher in children and young adults than in adults. • MH represents an acute episode of hypermetabolism and muscle injury related to the administration of halogenated anesthetic agents or succinylcholine. in . and with the administration of dantrolene sodium.

PRINCIPLES OF OPERATIVE SURGERY • OPERATING ROOM • The operating room should be an extension of the classroom for surgical trainees and practicing surgeons. • Alternative procedures should be considered if circumstances require it. .

should have a temperature control panel that allows room temperature to be modified rapidly when dealing with a hypothermic patient.The modern operating room for a trauma service. . in particular.

better with electric clippers than shaving with razor .Preop skin preparation • Preop skin preparation of both patients and surgeons is important • Hair removal if needed .

.Hemostasis • adequate hemostasis. in operating field with extremely confined space or dealing with delicate vessels • Temporary occlusion of the aorta at the esophageal hiatus with a compression device such as a T-bar or vascular -clamp or manual compression should be considered.more precise dissection and shorten operating time and the recovery time • Hemoclip application acceptable.

Hemostasis • a partial vascular injury need to be extended or converted to a complete transection to allow for better repair. . may best be treated with packing alone or in conjunction with angiographic embolization to achieve temporary control followed by a second-look operation. • Bleeding from multiple sites in a trauma patient. This approach is particularly applicable to injury of the aorta and vena cava.

• when proven infection or contamination is a concern. nonbraided suture preferred. . monofilament. temporary closure preferable.Wound Closure • In a patient with a condition requiring re-exploration or one suffering from abdominal compartment syndrome.

non dissolvable suture In a cirrhotic patient with established ascites the abdomen be closed with running suture. malnourished cancer patient. permanent closure with. • .Wound Closure • For abdominal wall closure in a debilitated. and a multilayer watertight closure must be achieved.

.Staplers • Surgical staplers have changed the practice of surgery in a profound way. most notably within the field of minimally invasive technology.

(2) ligating and dividing staplers (LDSS) (3) gastrointestinal anastomosis (GIA) staplers (4) thoracoabdominal (TA) staplers (5) end-to-end anastomosis (EEA) staplers (6) laparoscopic hernia mesh tackers (7) open hernia mesh staplers .Different stapling devices (1) skin staplers.

such as stapler lines of lung or pancreatic resection. . To prevent lymphatic leakage after a complete lymphadenectomy in the axilla or groin To prevent leakage from tissue surfaces which have been newly transected. to close fistulae.Surgical Adhesive • Fibrin seal adhesive used .

• Cyanoacrylate used for repair of organs and as an adhesive in many orthopedic procedures.Surgical Adhesive • Two other commonly used agents are 2-octylcyanoacrylate (Dermabond) butyl-2-cyanoacrylate (Histoacryl). • Dermabond demonstrated as an adequate replacement for the traditional suture closure of simple skin lacerations .

Thank you .