The Operation, Its Preop Preparation and Postop Care
At the end of the study, the student should be able to:
1. Identify the preop, operative, and postop phases in the management of a patient with a surgical condition.
2. Identify the elements in the preop management of a patient with a surgical condition.
3. Identify the elements in the operative management of a patient with a surgical condition.
4. Identify the elements in the postop management of a patient with a surgical condition.
Tasks to perform:
Given two cases with a narrative chronological description of the management (the paragraphs are numbered to facilitate your answering task No.1) –
1. For each case, identify the preop, operative, and postop phase. Use the paragraph numbers in the case.
2. For each case, identify the elements in the preop phase (surgeon’s tasks, duties, and responsibilities to the patient).
3. For each case, identify the elements in the operative phase (surgeon’s tasks, duties, and responsibilities to the patient).
4. For each case, identify the elements in the postoperative phase (surgeon’s tasks, duties, and responsibilities to the patient).
A 16-year-old Filipino male consulted a surgeon for a right lower quadrant abdominal pain which started two days ago. There was no associated bowel or urinary disturbance.
On physical examination, there was a definite and persistent direct tenderness and guarding over the right lower quadrant of the abdomen. There was no other significant findings.
Based on the physical examination findings and the other associated data, the surgeon made a clinical diagnosis of “acute appendicitis”.
The surgeon discussed the diagnosis with the patient and his guardian. He recommended an operation. The guardian consented to the recommendation of the surgeon.
After the surgeon made a screening for any medical problem that might interfere with the operation and after finding none, he scheduled the operation two hours after. He maintained the patient on nothing by mouth prior to the operation. Since the pain was tolerable, the surgeon did not give any analgesic anymore.
Two hours after, the patient was at the operating room ready for the operation. After the anesthesiologist had administered a spinal anesthesia, the surgeon placed the patient on a supine position. He then cleansed and placed antiseptic solution over the whole abdomen. He then placed sterile drapes over the contemplated operative field. After proper gowning, the surgeon made a transverse right lower quadrant incision to enter the peritoneal cavity. Upon entering the cavity, he saw the appendix to be inflamed and with minimal suppuration. He then removed the appendix. After checking for bleeding and after a correct count of instruments and sponges, the surgeon closed the abdominal incision. A dressing was then placed.
The patient was brought to the recovery room. After two hours, he was transferred to his room.
Analgesics were given to alleviate the postoperative pain. Intravenous fluid started before the operation was discontinued after it was consumed. Diet was started as soon as patient felt like eating.
The day after the operation, the patient was discharged with the following instructions:
1. How to take care of the wound
2. What potential problems to watch out for
3. Home medications
4. When to come for a check-up
One week after, the patient came back for a check-up. On inspection of the wound, there were signs of wound infection. The wound was opened and pus came out. The open wound was then cleansed and a dressing placed. The guardian was instructed on how to take care of the wound at home.
The patient had regular visits with the surgeon for four weeks until the wound was completely free of infection.
A 45 year old Filipino female consulted a general surgeon because of a breast lump she personally discovered two weeks prior.
The surgeon examined her breasts and found a 4 cm hard nontender mass on her right breast. The mass had an ill-defined border and fixed to the overlying skin. There was also a 2 cm right axillary mass.
After the physical examination, the surgeon made a clinical diagnosis of “right breast cancer and right axillary nodal metastasis.”
Assessing the patient not being ready to accept a cancer diagnosis at this point in time, the surgeon decided not to declare his clinical diagnosis. He just told the patient that she had a right breast mass, the exact nature of which was still not certain. It was a toss-up between a benign and a malignant tumor. She was advised to have a needle biopsy, which could be done in the clinic of the surgeon. After the surgeon explained the nature and the advantages of the needle biopsy, the patient consented and the procedure was performed. The patient was then advised to go back to the clinic after three days for the result of the biopsy and advice on subsequent treatment.
Three days after, the patient went back to the surgeon. At this time, the result of the needle biopsy was already in and it showed malignant cells.
The surgeon re-examined her breasts to recheck his suspicion of a breast cancer. He also examined her thoroughly in anticipation for a surgical treatment that he might suggest to the patient. For the latter, the surgeon determined whether surgery was still feasible considering the size of the tumor and he also looked for any medical problem that might interfere with the performance and the results of the operation.
The surgeon then slowly and gently told the patient the diagnosis of her breast mass, which was a right breast cancer with right axillary nodal metastasis. He tried to correct the patient’s equation of a death sentence with cancer. He told her there was still some means and some hope to live long.
The surgeon then discussed with the patient all the possible treatment options. The surgeon recommended a surgical procedure called a modified radical mastectomy. He explained to her the procedure, its nature, its advantages, and possible complications. He told her how many days the patient would have to stay in the hospital.
The surgeon also calculated the expenses the patient would have to spend for the treatment.
Whatever the patient needed to know and to whatever questions the patient asked, the surgeon gave a clear and supportive explanation and answer.
After the patient consented to the recommended treatment, a date was set. The surgeon then gave the patient a hospital admission slip. He also gave her a prescription to buy some materials needed in the operation and not available in the hospital.
The patient was admitted on the set date. She was operated the next day.
After the patient was given anesthesia by the anesthesiologist, the surgeon placed the patient in a supine position. He then cleansed and placed antiseptic solution over a wide area on the right chest wall. He then placed sterile drapes over the contemplated operative field. He made a transverse elliptical incision around the breast tumor after which he did a total removal of the right breast and then continued on to the right axilla to remove the entire fat pad in the said area. After the extirpative procedures, the surgeon checked for any bleeding points and stopped them, if any. He then placed a tube drain. After a correct count of instruments and sponges, the surgeon closed the wound and then placed a dressing. After the operation, what could be seen on the right chest of the patient were 1) a horizontal incision with several cotton stitches and 2) a transparent tube draining out serosanguinous fluid.
At the recovery room, the patient’s vital signs were monitored until they showed trends toward stability. She was also given oxygen and analgesics. After two to three hours in the recovery room, she was transferred to her room.
In her room, she continued to receive analgesics. Her intravenous fluid was discontinued. She was allowed resumption of her diet when she became fully awake. The drainage through the tube was monitored as to color and amount.
While the patient was still in the hospital, the surgeon took care of the wound and the tube drain. The surgeon looked for any wound complications that might occur.
On the fifth day after the operation, when the amount of drainage came down to 25 cc on a 24-hour measurement, the tube drain was removed. The patient was discharged thereafter with the instructions on the following:
1. How to take care of the wound.
2. What potential problems to watch out for.
3. What medicines to take at home.
4. When to go back to the surgeon for check-up.
5. When to take a bath.
One week after discharge, the patient went back to the surgeon. The wound was examined. It was dry. There was no seroma formation.
The histopathologic report of the breast and axillary specimens was already in. The report showed “invasive ductal carcinoma with metastasis to one out of ten axillary lymph nodes.” The report was communicated to the patient.
the surgeon advised chemotherapy because of the presence of nodal metastasis. The patient consented.
The patient came back a week after to start the chemotherapy treatment to be instituted by the surgeon. The chemotherapy treatment continued on an every three-week basis. After 5 to 6 months, the chemotherapy was completed. Thereafter, the patient was advised to come back for a regular check-up for the rest of her life.
ROJ Writing in 1999