Surgical procedure

G. Weber M.D., Ph.D

Professor of Surgery

Department of Surgical Research and Techniques Medical Faculty, Semmelweis University

Surgery

•is an ancient medical specialty •using operative manual and instrumental techniques •on a patient •to investigate and/or treat •a pathological condition (disease or injury)

An act of performing surgery: surgical procedure, operation, or simply surgery. In this context, the verb operate means to perform surgery.

Safe surgery

Pain – anaesthesia

Concept of infection

Discovery: Pain – anaesthesia

In October 16, 1846 the young William Morton got the opportunity from Prof. J. Warren, in Boston, to try his new miracle potion (ether) to anaesthetise a patient prior to a cervical tumor resection.

Anesthesia

Because surgery is generally painful, it is almost always proceeded by the administration of some type of anesthesia, blocks the perception of pain.

Local anesthesia Regional anesthesia General anesthesia

The choice of anesthesia should take into account the patient’s wishes, the anesthesiologist’s expertise, and special surgical problems.

Concept of infection

Ignaz Philipp Semmelweis (1818 – 1865) a Hungarian obstetrician who worked to identify the cause of puerperal sepsis. Semmelweis carefully compared mortality rates among obstetrical patients in two Viennese clinics.

Ignaz Philipp Semmelweis (1818 – 1865)

The first clinic was staffed by medical students and physicians whose hands became contaminated while performing autopsies. The second clinic, with significantly lower mortality rate, was staffed by midwives who did not perform autopsies.

Ignaz Philipp Semmelweis (1818 – 1865)

The mortality rate of women declined from 18% to 2% in only 5 Months. Unfortunately, Semmelweis was unable to convince his colleagues of the importance of handwashing.

He implemented a program which required medical students to wash their hands in liquid chlorine after performing autopsies.

Surgical procedure

Based on timing: Three categories of surgery are known

emergency,

urgent,

elective.

The indication for surgery

Emergent procedure

(for example, a ruptured aortic aneurysm) leave very little time for evaluation.

The indication for surgery

Urgent procedure: ileus

require surgery soon, but the operation can usually be delayed some hours to accommodate further evaluation and improve- ment of existing pathology.

Urgent procedure: embolectomy

Within 6 h!!!

The indication for surgery

Elective surgery

such as hernia repair, can be delayed for some

period of time, until everything has been done to optimize a person's chances of doing well during and after the surgical procedure.

Elective surgery : abdominal hernia repair

The indication for surgery

Elective surgery

The indication for surgery

Elective surgery

„Salus ægroti suprema lex”

the right operation is performed for the right reasons, accurately and expeditiously, on the right patient at the right time.

„The well-being of the patient is the most important law."

Pre-operative evaluation

Has two important goals:

For the patient to get a feeling of security and optimal peri-operative medical care, together with information concerning the surgery and anaesthesia.

For the surgeon and anaesthetist to get an objective picture of health and physical readiness for the operative procedure.

General Preoperative Questionnaire

Any serious illness in past

Do you fell unwell, cough, wheeze, edema, CP on exertion

Do you take any medicines, excessive alcohol, or have allergies

Familiar or personal history of bleeding problems

Anesthesia exposure in last 2 months; patient or family problems with anesthesia

If all answers no, normal BP and pulse, age < 60, non-major surgery, no further workup is necessary

Cardiac Evaluation

Shortcut: If > 2 of 3 positive answers, needs noninvasive testing

Are any clinical predictors present?

i. Class 1 or 2 mild angina ii. Prior MI iii. Compensated or prior heart failure iv. Diabetes v. Renal insufficiency

Is functional capacity low? Can not run a short distance, climb a flight of stairs,

or do heavy work around the house Is it a high surgical risk procedure?

i. Aortic repair or peripheral vascular surgery ii. Prolonged surgery with fluid shifts, blood loss iii. Emergent major operations

Pre-operative evaluation

All organ systems should be evaluated by history, with emphasis on the cardiovascular, respiratory and central nervous system, liver, kidney and haematology as vital functions.

Pre-operative evaluation

PHYSICAL EXAMINATION

The emphasis in the preoperative examination is truly on a head to toe examination.

Patients should be examined in supine and recumbent positions for end organ pathology.

The extent of further investigations is decided by the history, the physical examination and the present therapy, the age of the patient, the type, extent and urgency of the planned operation.

Extent of surgery

High-risk procedure Emergency surgery Large blood loss Aortic or peripheral vascular surgery

Intermediate-risk procedure Abdominal or thoracic op. Head and neck surgery Carotid endarterectomy Orthopedic surgery Prostate surgery

Low-risk procedure Breast surgery Cataract surgery Superficial surgery Endoscopy

High-risk procedure: Aorto-bifemoralis bypass implantation

Hand-assisted laparoscopic aorto-bifemoralis bypass implantation

High-risk procedure: peripheral vascular surgery

Femoro-popliteal bypass using saphenous vein

Femoro-poplitealis bypass with PTFE graft

Infected vascular graft

Intermediate-risk procedure: abdominal hernia repair

Major surgery

usually involves the use of general anesthesia.

Major surgery often involves opening one of the major body cavities— the abdomen (laparotomy), the chest (thoracotomy), or the skull (craniotomy)—and can stress vital organs.

Minor surgery

Can involve the use of local, regional, or general anesthesia.

Major body cavities are not opened.

May be performed in an emergency department, an ambulatory surgical center, or a doctor's office.

Vital organs usually are not stressed, and surgery can be performed by a single doctor.

Usually, the person can return home on the same day that minor surgery is performed.

THE RISK ASSESSMENT

After taking the history, physical examination and special investigations, and integrating the results, the preoperative risk assessment is done.

The peri-operative risk consists of the anaesthetic and the surgical risk.

Both are difficult and must be seen separately as they influence each other.

THE RISK ASSESSMENT

The following factors have the largest influence on morbidity and mortality peri-operatively:

Pre-morbid conditions.

Type, extent, urgency and planned duration of the operation.

The anaesthetic technique (e.g. hypotensive anaesthesia).

The post-operative monitoring.

PATIENT’S INFORMED CONSENT

After risk assessment the surgeon works out the operative plan and discuss the plan with the patient.

The patient’s own choice should be taken into account if possible.

The patient has to give informed consent.

The surgeon has to inform the patient about the operative management, explain alternative techniques with their advantages and disadvantages.

Only if the patient is fully informed, can he give informed consent.

Second Opinion

The choice to undergo surgery is not always clear, and there may be several options for the kind of surgical procedure.

Thus, a person may seek the opinion of more than one doctor.

Some medical insurance plans require a second opinion for elective surgery.

Some experts advise establishing up front that the doctor giving the second opinion will not perform the operation, so that there is no conflict of interest.

Second Opinion

Others advise obtaining a second

opinion from a doctor who is not a surgeon, to eliminate any bias toward surgery when nonsurgical treatment is an option.

However, some experts recommend that another surgeon give the second opinion, believing that a surgeon knows more about the advantages and disadvantages of surgery than would a nonsurgeon.

„Salus ægroti suprema lex”

Sensitive communication of the nature and severity of the disease

clear explanation of the proposed treatment

A knowledgeable patient who participates in his or her treatment will get better faster.

A patient must not be allowed to give up hope.

Patient safety problems

A number of studies suggest that

approximately 10% of patients admitted to hospital suffer from some kind of harm.

Up to 98 000 hospital deaths occur in the USA as a result of medical error each year Kohn et al. To err is human: building a safer health system. Washington National Academy Press, 2000.

In the 70s, after several aeroplane

crashes, investigators looked for causes.

AEs in the OR from 35% to 66%

Evaluation of errors:

communication failures

are the major causes

Great impact of non-technical

skills on technical performance

and clinical outcomes

Adverse events

Substantial proportion of adverse events are attributed to poor teamworking and related skills – incl. situation awareness and coordination between team-members in the OR

Studies of safety in other high-risk industries

show that adverse events are primarily attributed to human failures, rather than technical malfunction

Surgical Safety Checklist

Surgical approach

Laparotomy Vertical incisions:

1. median laparotomy

made through the fibrous tissue of the linea alba superior and/or inferior to the umbilicus

2. paramedian laparotomy 3. vertical transrectal

laparotomy 4. pararectal laparotomy

1

2

3

4

median laparotomy

Incision through the fibrous tissue of the linea alba superior and inferior to the umbilicus

paramedian incision

1

2

1

2 paramedian incision: through the anterior layer of the rectus sheath which is laterally retracted, and then through the posterior layer and peritoneum to enter the peritoneal cavity

2

median laparotomy paramedian laparotomy

Laparotomy: direction of incision

1

2

3

4

2. paramedian 1. median

3. transrectal 4. pararectal

Laparotomy on the abdominal wall

Transverse incisions:

1. horizontal transrectalis laparotomia

2. Pfannenstiel (Cosmetic, low incidence of hernia and dehiscence

Limits exposure to lateral pelvis and upper abdomen

2

1

Laparotomy on the abdominal wall

McBurney-incision

is an oblique incision inferomedially directed, and splits the fibers of the external oblique aponeurosis, fibers of internal oblique and transverse abdominal muscles are likewise split to gain access to the appendix

Laparotomy on the abdominal wall

1. McBurney-incision

2. inguinal transmuscular laparotomy

3. paracostal (Kocher) laparotomy

4. subcostal laparotomy 1 2

4 3

Vertical vs transverse incision

Vertical

Quick entry into abdominal cavity

Less blood loss

Excellent exposure

Increased risk of wound dehiscence and hernia

Less cosmetic

Transverse

More cosmetic along transverse Langer’s lines

Fascia opened along transverse fibers

Increased blood loss from transection of epigastric

Nerves run vertically and more likely to be transected

Thoracotomy

A: axillar thoracotomy B: extended axillar thoracotomy C: anterior intercostal thoracotomy D: Median sternotomy

Thoracotomy

A: postero - lateral B: antero - lateral

Thoracolaparotomy

Laparoscopic approach compared to open surgery for cholecystectomy

Incisions on the face

Subpalpebral

Subangular

Subciliar

Incisions on the neck

Dieffenbach Submandibular MacFee Schobinger