Preoperative preparation

General Surgery Principles part 1

Preoperative preparation
The preoperative assessment involves an overall analysis of the patient’s
condition and preparation of the patient for the proposed procedure. This involves
taking a careful history, confirming that the indication for surgery still exists (e.g.,
that the enlarged lymph node that was to be removed for biopsy has not
spontaneously regressed), and that the patient is fit for the procedure.
AIM: To optimize post operative status of the patient, ensure the wellbeing of the
patient and success of the planned surgery
Method: find and correct risk factors & prevent expected complications
Do not accept someone else’s diagnosis – it might be wrong.
Preoperative evaluation includes history, examination, investigations, and
operative factors affecting preoperative management.
Patient assessment:
• History of presenting complaint and detailed history of present illness
• Past medical history: Diabetes, chest or heart disease, hepatitis or any
chronic illness or medications.
• Past surgical history: Nature of previous operations, any complications or
blood transfusion, complications of previous surgery
• Past anesthetic history: Difficult intubation, aspiration during anesthesia,
Scoline apnea, malignant hyperpyrexia
• Social habits: Smoking, alcohol, substance abuse
• Allergy to any drugs
• All patient’s medications should be continued
Examination:
❑ Vital signs: blood pressure, heart rate, RR & temperature.
❑ Chest and heart.
❑ Proper Local Examination
Investigations:
Tailored to condition of patient & nature of the operation.
➢ Blood picture.

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➢ Coagulation profile: PT, PTT, and INR.
➢ Fasting blood sugar and 2-hour postprandial.
➢ Liver function tests; ALT, AST, ALP & serum albumin.
➢ Hepatitis markers and HIV
➢ Kidney function tests: creatinine and BUN
➢ Chest X-ray (not a routine test in all hospitals)
➢ ECG (routine in major surgery and with the patients over 40 years)
➢ Specific tests that depend on the disease, e.g., Thyroid functions in patients
with thyroid diseases.
Operative factors affecting preoperative management.
This includes:
➢ Risk of anesthesia (assessed by ASA)
➢ Risk of surgery
The American Society of Anesthesiologists (ASA) has produced a grading
scheme to estimate co-morbidity.
I→ Healthy patient
II→ Mild systemic disease with no functional limitation
III→ Severe systemic disease with definite functional limitation
IV→ Severe systemic disease that is a constant threat to life.
V→ Morbid patient unlikely to survive 24 hours with or without operation.
This is an objective way for operative risk assessment.
Risk of surgery depends on the type of surgery:
• Nature of the surgery: Some operations require special preparation of the
patient, such as bowel preparation prior to colonic surgery or preoperative
localization of an impalpable mammographic abnormality prior to breast
surgery.
• Emergency or elective surgery. Emergency surgery is usually riskier than
an elective one.

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• The cardiac & aortic operations (the most serious) followed by other
thoracic & abdominal operations while least serious are operations on skin
&S.C. tissue.
Hospital admission and fasting
Usually, patients are admitted to the hospital the same day or the Day before
surgery.
If complex assessment or preparation is required , admission to the hospital is
done several days before the surgery.
In emergency and Urgent surgeries , hospital admission is done immediately.
Fasting before surgeries is required to reduce risk of pulmonary aspiration.
The recommendations are :
• 2 hours fasting for clear Fluids .
• 4 hours fasting for breast milk.
• 6 hours fasting for infants’ formulas.
• 6 hours fasting for non-human milk.
• 6 hours fasting for light meal.
Prophylactic anticoagulants against venous thromboembolism
Pulmonary embolism is the most common cause of preventable
postoperative mortality.
Indications:
▪ Major surgery, particularly cancer operations.
▪ Obesity.
▪ History of DVT or PE.
▪ Females on estrogen as contraceptive or HRT
Method:
Heparin(SC): LMWH is preferred because: →
A. Lower risk of bleeding than unfractionated heparin

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B. Needs no monitoring c) given once daily.
• Start: few hours before surgery
• Duration: till patient is adequately ambulant, commonly one week. May
increase in some surgeries.
• Example: enoxaparin 1 mg/kg/day in a single daily dose
Prophylactic antibiotics:
Against surgical site infection (SSI): discussed in detail with surgical infection.
Indication: clean contaminated or contaminated surgery & wounds where FB is
implanted.
Time of administration: pre-operatively (1 hour before surgery) & sometimes
during the operation in lengthy operation and in the early post-operative period
Commonly used: First generation cephalosporin (cephazolin) however each
hospital has an infection control committee that recommends an antibiotic
according to its prevalent microorganisms.
Against bacterial endocarditis
Indications: congenital heart disease and prosthetic cardiac valves
who will have operations in the oral cavity, the respiratory tract or in an infected
area.
Usually use → Amoxicillin
Prophylaxis Against Gastro-duodenal Ulceration
Proton pump inhibitors are indicated in all major operations.
Special situations
Emergency surgery:
• Examples: those done for severe trauma, massive hemorrhage, and major
sepsis
• Result in higher morbidities and mortalities than elective ones.
• Aim: saving life followed by finding the definitive diagnosis and dealing
with it as in management of severe trauma:

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− Primary survey → focuses on life saving measures.
− Secondary survey → diagnosis while resuscitation is continued
− Tertiary survey → directed towards definitive management.
− For I.O. →focus on preoperative correction of fluid, electrolyte &
acid/base imbalances before taking patient to OR
− With severe bleeding → give blood & fluids with oxygenation
-In desperate conditions, definitive surgery is carried out before full optimization
as in splenectomy for severely bleeding ruptured spleen.
Chronic smokers:
▪ There is 5-fold increase in postoperative respiratory infections (due to
reduced muco-ciliary function that impairs mucus clearance)
Carboxyhemoglobin → ↓O2 carrying capacity → Tissue hypoxia.
▪ Smoking increases platelet aggregation → increases the risk of
thromboembolic manifestations as stroke & MI perioperative.
▪ Smoking should be stopped 6-8 weeks before elective surgery.
Management of pre-existing medical conditions
Diabetes:
I- Perioperative problems
1- Prone to develop hypoglycemia, hyperglycemia & ketoacidosis.
2- May have renal & vascular (coronary& cerebrovascular) diseases
II- General Principles of management
• A team of anesthetist, diabetologist nephrologist and may be cardiologist
is needed.
• Ensure patients compliance to their drugs.
• Frequent blood sugar measurement before, during & after the operation
and values corrected.
• Patients with diet-controlled diabetes require no special preoperative
treatment.

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• Patients on oral hypoglycemics or subcutaneous insulin should stop
therapy the night before and be commenced on a glucose and insulin
infusion.
• Long-acting insulin preparations should be avoided the night before major
surgery to prevent unexpected intraoperative hypoglycemia.
• Patients with diabetes should be placed first on the operating list.
• For operations under local anesthesia, the patient is not fasting.
→ no need to change medications’ doses and frequencies.
• For minor & moderate operations, the patient is fasting but is expected to
resume oral intake within a few hours afterwards, oral hypoglycemic and
insulin are withheld until full intake is resumed (IV insulin is administered
if hyperglycemia develops)
• For major surgery, the patient is expected to be fasting for longer period→
give IV insulin guided by a sliding scale, until full oral intake
Respiratory disease:
Pulmonary function test and assessment by chest consultant before surgery in
patients with respiratory diseases
Cardiac disease:
Patients with cardiac disease must be referred to a cardiologist for improved
management. Routine electrocardiogram (ECG) and echo should be done.
Exercise ECG, stress echocardiogram or radionuclide myocardial perfusion scan
may be needed.
Local anesthesia should be considered in all patients with a history of cardiac or
respiratory disease.
➢ The peak incidence of MI in the postoperative period is around 3rd
postoperative day → mortality rate 25% (high)
➢ The most important screening test → ECG, however, about 25%of proven
ischemic heart disease patients have normal ECG.
➢ Patients with history of chest pain should be further investigated by stress
exercise testing, multislice CT or coronary angiography→ assess the
severity of CAD→ prompt treatment.

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➢ If coronary revascularization is indicated, stenting or coronary bypass
should be undertaken before any other major surgery.
➢ All anti-anginal drugs especially beta blockers should be continued
through preoperative and early postoperative periods.
➢ The strongest predictor of postoperative cardiac mortality is active heart
failure, followed by MI in the past 6 months, if present → postpone
elective surgery
➢ - 50% of mortality rates following major operations are due to MI when
significant CAD is not properly evaluated
➢ - For medium & major surgery → discontinue anti platelets for 7-10 days
& anticoagulants 4-5 days before surgery and replace with heparin
Patients with arterial hypertension
• Diastolic pressure that is > 110mmHg is an indication to postpone elective
surgery until adequate control is obtained.
• Beta blockers are the ideal drugs for blood pressure control and for
reducing the incidence of myocardial ischaemia and mortality. 3-
Exclusion of a possible secondary hypertension, e.g., pheochromocytoma,
renal artery stenosis, coarctation of the aorta
Patients with cardiac arrhythmias
▪ The use of monopolar electrocautery may interfere with the function of a
pacemaker.
▪ A cardiac technician should be available during the operation and in the
postoperative period to adjust any malfunction.
▪ An alternative energy source for coagulation is used, e.g., bipolar
electrocautery or ultrasound-activated device (harmonic scalpel)
Obstructive jaundice patients:
Patients with obstructive jaundice often have a prolonged prothrombin time and
require vitamin K and either human prothrombin complex (e.g., Beriplex) or fresh
frozen plasma prior to surgery to correct the abnormality. They are also more
prone to infection and poor wound healing. Intraoperatively, it is important to
maintain a diuresis with judicious fluid replacement and diuretics (such as
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mannitol) to prevent acute renal failure (hepatorenal syndrome) to which these
patients are susceptible.
In the presence of liver impairment, metabolism of some commonly used drugs
may be reduced.
Possible complications
• Bleeding tendency (because of deficiency of fat-soluble coagulation
factors)
• Infection of stagnant bile → cholangitis → septicemia
• The absence of bile salts in the intestine → weakens the gut barrier &
allows bacterial migration from colon to blood stream 4- Liver and renal
(hepatorenal) failure.
Prophylactic measures for jaundiced patients
• IV 10 mg vitamin K1 /8-12 hours → allow the liver to synthesize
prothrombin & other coagulation factors.
• FFP should be prepared & given preoperatively if INR is elevated> 4
(contains ready-made coagulation factors) 3- Adequate pre- and
postoperative hydration.
• Perioperative antibiotics
Chronic renal failure and renal impairment:
Patients with chronic renal impairment (not dialysis dependent)
▪ Avoid hypotension → precipitates acute renal failure.
▪ Avoid nephrotoxic drugs & drugs metabolized in the kidney, if needed,
adjust dose according to renal function as NSAID.
Chronic renal failure patients who are on dialysis
▪ Dialysis is performed the day before surgery.
▪ Check urea & electrolytes pre-& post dialysis then twice daily after
surgery.
▪ Postoperative dialysis should start as soon as the patient is
hemodynamically stabilized.

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▪ The patient should be carefully monitored for:
a) Hyperkalemia & acidosis
b) Anemia
c) Coagulation defect
d) Fluid overload
Other problems
Bleeding disorders or anticoagulation: Patients should be managed in close
collaboration with the hematology department. Patients with hemophilia A or B
should be given the specific clotting factor replacement.
Patients on warfarin should be converted to heparin preoperatively. When
patients are anticoagulated on account of previous thromboembolic disease,
additional prophylaxis should be given, including measures such as stockings,
intermittent compression boots while on the operating table and early
mobilization (when possible, with local anesthesia to facilitate this). Rapid
reversal of warfarin may be achieved with clotting factor replacement (human
prothrombin complex, e.g., Beriplex) or pooled fresh frozen plasma.
Postoperative Care
Postoperative care:
• Immediate (Post-Anesthetic) Phase (1)
• Intermediate (Hospital stay) Phase (2)
• Convalescence (After discharge to full recovery)
Immediate postoperative period starts with complete recovery from Anesthesia
and lasts for the rest of the hospital stay.
Immediate (Post-Anesthetic) Phase (1):
Aim:
• Homeostasis
• Pain Management
• Prevention and Early Detection of complications and proper management

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Causes of Early Morbidities
• Acute Pulmonary Problems
• Cardiovascular Problems
• Fluid and Electrolyte Imbalances
Prevention:
Recovery Room :
1- Anesthetic Management of Cardiopulmonary and Neurological Functions
2- Surgical Management of the Operative Site
• Trained Nursing Staff:
To implement Anesthetic and Surgical Instructions
• Continuous Monitoring of the Patient:
(Vital Signs, O2 Saturation, Pain, Conscious Level, Surgical Site, etc.)
Transfer from the recovery room:
1- Transfer the patient to the ward after adequate stabilization of cardio-
pulmonary and Neurological Functions
2- Transfer to the ICU: if the patient is critically ill
Immediate (Hospital stay) Phase (2):
Ward management:
a) Monitoring
• Vital signs (HR, BP, RR, Temp)
• C.V.P. (Central Venous Line, or Swan-Ganz catheter for pulmonary
artery wedge pressure; PAWP)
• Arterial Line for continuous BP measurement
• ECG
• Fluid Balance (intake and output)
• Urinary Catheter measurement and care

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 General Surgery Principles part 1
• Other types of monitoring :
• Arterial pulses after vascular surgery.
• Level of consciousness after neurosurgery.
b) Respiratory Care:
• O2 mask, Tracheal suction, Chest physiotherapy
c) Position in bed and mobilization:
• Turning in bed usually every 30 min. until full mobilization
• Special position if required.
• DVT prevention mechanically ( intermittent calf compression)
d) Diet:
• NPO
• Liquids
• Soft diet
• Normal or special diet
e) Administration of I.V. fluids:
• Daily requirements
• Losses from G.I.T and U.T.
• Losses from stomas and drains
• Insensible losses
• Care of renal patients
• Care of drainage tubes
f) Medications:
• PPI, or H2 Blockers
• Opioids
• Pain killers
• Antibiotics
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 General Surgery Principles part 1
• Anti-Coagulants
• Anti Diabetics
• Anti-Hypertensives
g) Lab. Tests and Imaging:
• To detect or exclude post-Op. complication.
h) Wound care
i) Special recommendations:
• Post-Op. atelectasis is enhanced by shallow breathing, pain, obesity, and
abdominal distension (restriction of diaphragmatic movements)
• Post-Op. physiotherapy helps to decrease atelectasis, with O2 mask and
periodic hyperinflation using spirometer.
• Early mobilization is of great help.
Fluids and electrolytes management:
Considerations:
• Maintenance requirements
• Extra needs resulting from systemic factors e.g., fever, burn diarrhea
and vomiting etc.
• Losses from drains and fistulas
• Tissue oedema (3rd space losses)
• The daily maintenance requirements in adults for sensible and
insensible losses are 1500-2500mls. depending on age, sex, weight
and body surface area and fluid chart
• Rough estimation of need is by body weight x 30/day. e.g. 70 KG x 30 =
2100ml/day
• Requirement is increased with fever, hyperventilation and increased
catabolic states.
• 5% dextrose in normal saline or in lactated Ringer’s solution is suitable for
most patients.

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 General Surgery Principles part 1
• Usual daily requirements of fluids are between 2000-2500ml/day.
• Estimation of electrolytes daily is only necessary in critical patients.
• Other electrolytes are corrected according to deficits.
Postoperative pain management:
• Factors affecting severity :
• Duration of surgery
• Degree of Operative trauma (intra-thoracic, intra-abdominal or
superficial surgery)
• Type of incision
• Factors related to the patient :
• Anxiety.
• Fear.
• Physical and cultural characteristics
Complications of Pain:
• Causes vasospasm.
• Hypertension
• May cause bleeding.
Management of Post-Op. pain:
• Physician – patient communication (reassurance)
• Parenteral opioids
• Analgesics (NSAIDS)
• Anxiolytic agents (Hydroxyzine) potentiate action of opioids and
has also an anti-emetic effect.
• Oral analgesics or suppositories e.g., Tylenol
• Epidural analgesia (for pelvic surgery)
• Nerve block (post-thoracotomy and hernia repair)

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 General Surgery Principles part 1
Post-Operative Care of GIT
• NPO until peristalsis returns.
• Paralytic ileus usually takes hours, may be up to 24hs.
• NGT is necessary after esophageal and gastric surgery.
• NGT is NOT necessary after cholecystectomy, pelvic operations, or
colonic resections.
• Gastrostomy and jejunostomy feeding tubes: feeding can start on 2 nd post-
Op. Day because absorption from small bowel is not affected by
laparotomy.
• Enteral feeding is better than parenteral feeding.
• Gradual return of oral feeding from liquids to normal diet
Enhanced Recovery After Surgery (ERAS)
• Enhanced Recovery After Surgery (ERAS) protocols have been developed
to decrease the amount of stress and gut dysfunction in individuals
undergoing elective colorectal surgery.
• ERAS leads to enhanced recovery and decreased morbidity and length of
stay.
• However, they are difficult to implement because of the relatively high
number of interventions that must be adopted simultaneously by a
multidisciplinary team.
• Pre-operative recommendations:
1) Pre-operative counseling and training
2) A curtailed fast (6 hours to solids and 2 hours to clear liquids) and pre-
operative carbohydrate loading
3) Avoidance of mechanical bowel preparation
4) Deep vein thrombosis prophylaxis using low molecular weight heparin
5) A single dose of prophylactic antibiotics covering both aerobic and anaerobic
pathogens
• Intraoperative recommendations
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 General Surgery Principles part 1
1) High (80%) oxygen in the peri-operative period
2) Prevention of hypothermia
3) Goal directed intra-operative fluid therapy
4) Preferable use of short incisions for open surgery
5) Avoidance of post-operative drains and nasogastric tubes if possible
6) Short duration of epidural analgesia and local blocks
• Post-operative recommendations:
1) Avoidance of opiates and the use of Paracetamol and non-steroidal anti-
inflammatory drugs (NSAIDS)
2) Early commencement of post-operative diet
3) Early and structured post-operative mobilization
4) Restricted amounts of IV fluids
5) Regular audit
Discharge of the Patient
• Factors affecting Decision to discharge the patient:
1. Patient cognitive status
2. Patient activity level and functional status
3. Ability to obtain medications and services.
4. The nature of the patient's current home and suitability for the patient's
conditions (e.g., presence of stairways, cleanliness)
5. Availability of family or companion support
6. Availability of transportation from hospital to home and for follow-up
visits
7. Availability of services in the community to assist the patient with ongoing
care.

When to discharge the patient?

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 General Surgery Principles part 1
• Patient Medical Condition is suitable.
• Ambulant or movement care is available.
• Can take medications.
• Perform self-care activities.
• Eat an appropriate diet or manage nutritional needs.
• Follow up with designated providers.

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 General Surgery Principles part 1

Post-operative
Complications

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 General Surgery Principles part 1
Post-operative Complications
Local Wound Complications
➢ Hematoma
➢ Seroma
➢ Infection
➢ Dehiscence
➢ Evisceration
➢ Incisional Hernia
Wound Infection
Surgical Site
Infection (SSI):
Infection that occurs at
the operative incision
site within 30 days
after surgery.
How to suspect & treat
surgical site
infection?

➢ Redness, swelling, pain &

tenderness, purulent discharge
wound dehiscence.
➢ Other indicators of infection
include fever.

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 General Surgery Principles part 1

What do you do?

Wound dehiscence – Management

• Dehiscence Operative repair

versus Conservative treatment
• Evisceration is a surgical
emergency.
• In all cases, correction of the
underlying cause is essential.
Burst Abdomen
➢ Partial or complete postoperative separation of an abdominal wound
closure with protrusion or evisceration of the abdominal contents
th
➢ Most commonly occurs from the 5th to the 8 postoperative day when the
strength of wound is at its weakest.
➢ Usually sutures opposing the deep layers, i.e., peritoneum and rectus sheath
tear through causing burst abdomen.

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Operative Treatment Tension Sutures

General post-operative complications

➢ Postoperative fever
➢ Pulmonary
➢ Gastrointestinal
➢ Collapse
➢ Cardiac
➢ Renal
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 General Surgery Principles part 1
➢ Thermal regulation
➢ Metabolic
➢ Neurological
Postoperative Fever
Local causes
➢ URTI
➢ Chest: Atelectasis & pneumonia &PE
➢ DVT
➢ Hematoma
➢ SSI
➢ UTI
➢ Cannula infection (central or peripheral)
➢ Anastomotic leak
Systemic causes
➢ Drug reaction (common)
➢ Transfusion reaction (uncommon)
➢ Rare causes
✓ Thyrotoxic crisis
✓ Malignant hyperthermia
✓ following GA
✓ Malaria

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 General Surgery Principles part 1
The 5 W’s

W POD Cause

Wind 1 Atelectasis, pneumonia

Water 3 UTI

Wound 5 SSI

Walking 7 DVT / PE

Wonder drug Penicillin, TB drugs.

DVT
Risk factors include:
➢ Increased age
➢ Obesity
➢ History of thromboembolism
➢ Varicose veins, the
➢ Oral contraceptive pills
➢ Malignancy
➢ Factor V Leiden gene mutation (hyper-coagulable states)
➢ Orthopedic surgery
Prophylaxis is the corner stone of management.

Respiratory complications
• Up to 15% of pts. Having GA
• Most commonly : atelectasis & Pneumonia
• Acute respiratory distress syndrome may affect severely ill patients.

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Gastrointestinal Complications
➢ Postoperative ileus
➢ GI bleeding
Collapse or rapid general deterioration
Important causes of postoperative Collapse:
Cardiovascular
• MI
• Arrhythmia
• Pulmonary embolism
• Stroke
Respiratory
• Failure to reverse anesthesia (early)
• Hypoxia due to respiratory depressant drugs
Surgical & infective
• Hypovolemic shock
• Systemic sepsis
Metabolic
• Hypo- or hyper-glycaemia in diabetics
• Electrolyte disturbances ( e.g., low Na)
• Adrenal insufficiency
Drug reactions (anaphylaxis)
Cardiovascular Complications
• Hypertension
• Ischemia/Infarction
• Leading cause of death in any surgical patient
• Key to treatment = prevention
• Arrhythmias
• 30 seconds of abnormal cardiac activity
• Key to treatment = correct underlying medical condition, electrolyte
replacement
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Renal Complications
• Urinary retention
• Inability to evacuate urine-filled bladder after 6 hours.
• Acute renal failure
• Oliguria < 0.5 cc/kg/h
• Pre-renal
• Intrinsic
• Post-renal
Complications of Thermal Regulation
• Hypothermia
• Drop in temp by 2° C.
• Temp below 35 ° C → coagulopathy, platelet dysfunction
• Risks: Increase risk of cardiac events, and blood loss and need for
transfusion
• SSI.
• Malignant hyperthermia
• Autosomal dominant, rare but fatal
• Presentation: fever, tachycardia, rigidity, cyanosis
• Treatment: Dantrolene 1 to 2 mg/kg →10 mg/kg total until symptoms
subside
Metabolic complications
Adrenal insufficiency
➢ Uncommon but potentially lethal giving rise to sudden cardiovascular
collapse
➢ Presentation: hypotension, fever, confusion, abdominal pain
Hyper/Hypothyroidism
Complications Specific to Particular Operations
Gastrointestinal surgery
➢ Anastomotic Leakage.
➢ Bleeding Or Abscess.
➢ Ileus

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Biliary surgery
➢ Biliary leakage, stricture, jaundice
Chest surgery
➢ All pulmonary complications
Anal surgery
➢ Anal stenosis, incontinence
Neurosurgical operations
➢ Disturbed level of consciousness, signs of increased intracranial tension,
paralysis, or paresis.

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