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

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

OTHERS INVESTIGATIONS
Electrolytes (Na+, K+)
LFT

AMYLASE
PT, APTT

SYSTEMS APPROACH TO PREOPERATIVE EVALUATION

Cardiovascular disease contributes to

perioperative mortality for noncardiac surgery significantly

Computation of the Cardiac Risk Index

Criteria Points History Age > 70 yr 5 Myocardial infarction < 6 mo 10 Physical examination S3 gallop or jugular venous distention 11 Aortic valvular stenosis 3 ECG Rhythm other than sinus or PACs 7 > 5 PVCs/min 7

 General status PO2 < 60 or PCO2 > 50 3 K < 3.0 or HCO3 < 20 mEq/L BUN > 50 or creatinine > 3.0 mg/dL Abnormal SGOT or chronic liver disease Bedridden Operation Intraperitoneal, intrathoracic, or aortic operation 3 Emergency operation 4 Total Possible 53 points

Preoperative cardiac risk

Class I (0 to 5 points) - 0.9% risk of serious cardiac event or death Class II (6 to 12 points) - 7.1% risk
Class III (13 to 25 points) - 16.0% risk Class IV (>26 points) - 63.6% risk

 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.

 Improvements in postoperative care centered on decreasing the adrenergic surge associated with surgery and halting platelet activation and microvascular thrombosis. Perioperative risk for cardiovascular

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

Pulmonary
Preoperative evaluation of pulmonary function necessary for either thoracic or general surgical procedures. Thoracic and upper abdominal resection cases, for thoracic procedures requiring single-lung

ventilation, and for major abdominal and

thoracic cases in patients who are older than 60

years of age,have significant underlying

 Necessary tests include the forced expiratory volume at 1 second (FEV1), the forced vital capacity, and the diffusing capacity of carbon monoxide.Adults with an FEV1 of less than 0.8 L/second, or 30% of predicted, have a high risk of complications and postoperative pulmonary insufficiency

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

 Diagnostic testing for patients with renal dysfunction should include electrocardiogram (ECG), serum chemistry panel, and

complete blood count (CBC). If physical examination findings are suggestive of heart failure, a chest radiograph may be helpful.
Urinalysis and urinary electrolyte studies not helpful in the setting of established renal

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

The patient with end-stage renal disease requires attention in perioperative period. Pharmacologic manipulation of hyperkalemia,

replacement of calcium for symptomatic

hypocalcemia, and the use of phosphate-binding antacids for hyperphosphatemia required

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

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

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

Acute hepatiti s

Patient with liver disease facing surgery

Obstructi ve jaundice

Postpone elective surgery

Chronic hepatitis Surgery safe

Cirrhosis Childs A&B:treat ascites,coagulopathy and proceed to surgery Childs C: postpone until class improved or cancel surgery

1. Pre op. fluid management 2. No dopamine/mannitol 3. Lactulose 4. Antibiotic prophylaxis 5. No routine preop. Biliary drainage 6. Coagulation parameter

Coagulopathy Target PT no more than 2 sec above normal 1.vit. K 2.FFP 3.Cryo ppt.

Ascites 1. Fluid restriction 2. Diuretics 3. 3.paracentesis

Encephalopathy 1.Lactulose 2.Avoid ppt.ing factors

Child-Pugh Scoring System 1 Encephalopathy None Ascites Absent Bilirubin (mg/dL) <2 Albumin (g/L) >3.5 PT <4 (prolonged sec) INR <1.7

Points 2 Stage I or II Slight 23 2.83.5 46

1.72.3

3 Stage III or IV Moderate >3 <2.8 >6 >2.3

Class A = 56 points; Class B = 79 points; Class C = 1015 points.

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

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

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

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

 These patients should be scheduled for early morning operation, when feasible. During operation, a standard 5% or 10% dextrose infusion is used with short-acting insulin or insulin drip to maintain glycemic control. 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

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

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. A low-dose ACTH stimulation test demonstrate abnormal response to adrenal stimulation and suggest the need for perioperative steroid supplementation. The amount of steroid administered and duration of treatment are titrated to the anticipated degree of perioperative stress. .

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

 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 -adrenergic blockade prior to surgery. One to two weeks is usually required to achieve adequate therapeutic effect by a blockade; this can be accomplished with either a nonselective agent such as phenoxybenzamine, or selective a1 agents such as prazosin.

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

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

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. platelet transfusion when counts < 50,000 in a patient at risk for bleeding.

Guidelines for Red Blood Cell Transfusion for Acute Blood Loss
Evaluate risk of ischemia. < 30% rapid volume loss not require transfusion in previously healthy individual. Measure hemoglobin concentration: < 6 g/dL- transfusion usually required; 610 g/dL- transfusion dictated by clinical circumstance; >10 g/dL- transfusion rarely required.

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. Tachycardia and hypotension refractory to volume suggest the need for transfusion; O2 extraction ratio > 50%, VO2 decreased, suggest that transfusion needed.

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

Recommendations for Perioperative Anticoagulation in Patients Taking Oral Anticoagulants

Indication Acute venous thromboembolism Preoperative Postoperative

Month 1
Months 2 and 3 Recurrent venous thromboembolism

IV heparin
No change No change

IV heparin
IV heparin SC heparin

Acute arterial embolism

Month 1 Mechanical heart valve Nonvalvular atrial fibrillation IV heparin No change No change IV heparin SC heparin SC heparin

Levels of Thromboembolism Risk in Surgical Patients Without Prophylaxis and Successful Prevention Strategies
Level of Risk Definition of Risk Level Calf DVT (%) 2 Proxi mal DVT (%) 0.4 Clinica Fatal l PE PE (%) (%) 0.2 0.002 Prevention Strategy

Low

Minor surgery in patients < 40 yr with no additional risk factors

No specific measures Aggressive mobilization LDUH q 12 hr, LMWH, ES or IPC

Moderate

Minor surgery in patients with additional risk factors: nonmajor surgery in patients aged 4060 yr with no additional risk factors; major surgery in patients < 40 yr with no additional risk factors

1020

2-4

1-2

0.10.4

Levels of Thromboembolism Risk in Surgical PatientsWithout Prophylaxis and Successful Prevention Strategies
Level of Risk Definition of Risk Level Calf DVT (%) 2040 Proxi mal DVT (%) 4-8 Clinical PE (%) Fatal PE (%) 0.4-1 Prevention Strategy

High

Nonmajor surgery in patients > 60 yr or with additional risk factors; major surgery in patients > 40 yr or with additional risk factors Major surgery in patients > 40 yr plus prior VTE, cancer, or molecular hypercoagulable state; hip or knee arthroplasty, hip fracture surgery; major trauma; spinal cord injury

2-4

LDUH q 8 hr, LMWH or IPC

Highest

4080

1020

4-10

0.2-5

LMWH, oral anticoagul ants, IPC/ES + LDUH/LM WH 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, visceral protein indicators, or prognostic indices) benefitted from preoperative parenteral nutrition

 Obesity BMI>40KG/m2 or BMI >35KG/m2 with significant comorbid condition increase mortality

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

Antibiotic Prophylaxis
Prophylactic antibiotics generally not required for clean (class I) cases, exception Indwelling prosthesis , 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. For abdominal (hepatobiliary, pancreatic, gastroduodenal) cases, 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 laparoscopic hernia repair

-- National Research Council Classification of Operative Wound

Clean (class I) Nontraumatic

No inflammation
No break in technique Respiratory, alimentary, or genitourinary tract not entered

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, without pus Transection of clean tissue for the purpose of surgical access to a collection of pus Traumatic wound with retained devitalized tissue, foreign bodies, fecal contamination, or delayed treatment, or all of these; or from dirty

Preop. Mechanical bowel cleansing

Oral antibiotic not beneficial, May increase post op. infection with Cl. Difficile Removal of bulk fecal material - increase anastomotic / infectious complication

Review of Medication
cardiovascular morbidity associated with the perioperative discontinuation of -blockers and rebound hypertension with abrupt cessation of the antihypertensive clonidine. 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 on the drugs half-life.

 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. Patients based on theory of decrease volume and acidity of stomach content ASA recommend adults stop intake of solid for at least 6 hrs, clean fluid for 2 hrs Pre op. Carbohydrate supllementation safe and improve patients response to perioperative stress.

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%. When suspected, the offending agent should be discontinued and the patient given epinephrine 0.3 to 0.5 mL of 1:1000 subcutaneously; in severe anaphylaxis, this is given IV and repeated at 5- to 10-minute intervals, as needed. Histamine-1 (H1 ) blockade with diphenhydramine 50 mg IV or intramuscularly.

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. MH treated by discontinuation of inhalational anesthetic agents and succinylcholine, and with the administration of dantrolene sodium, in doses of 2 to 3 mg/kg .

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.

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

Preop skin preparation

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

Hemostasis
adequate hemostasis- more precise dissection and shorten operating time and the recovery time

Hemoclip application acceptable, 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.

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

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

Wound Closure
For abdominal wall closure in a debilitated, malnourished cancer patient, permanent closure with- non dissolvable suture In a cirrhotic patient with established ascites the abdomen be closed with running suture, 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.

Different stapling devices

(1) skin staplers; (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 (8) endo-GIA.

Surgical Adhesive Fibrin seal adhesive used

.
to close fistulae, To prevent lymphatic leakage after a complete lymphadenectomy in the axilla or groin To prevent leakage from tissue surfaces which have been newly transected, such as stapler lines of lung or pancreatic resection.

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

Thank you