The Operation, Its Preop Preparations and Postop Care

THE OPERATION, ITS PREOP PREPARATIONS AND POSTOP CARE

REYNALDO O. JOSON, M.D.
1992; 2000

SPECIFIC OBJECTIVES:

At the end of the session, the students should be able to:

1. Define what an operation is.

2. Indicate the two purposes of an operation.

3. Identify at least six items to discuss with a patient once a decision is made that an operation is needed and before a consent is obtained.

4. Enumerate the essential elements of preoperative preparations.

5. Give at least four types of therapeutic operative procedures based on objective.

6. Give at least four types of therapeutic operative procedures.

7. Enumerate chronically the essential steps of an abdominal cavity operation done under general anesthesia.

8. Enumerate chronically the essential steps of an excision of a sebaceous cyst in the nape done under local anesthesia.

9. Enumerate the essential elements of a postoperative care.

10. Interrelate the operation, its preop preparation and its postop care in terms of importance.


THE OPERATION, ITS PREOP PREPARATIONS AND POSTOP CARE

REYNALDO O. JOSON, M.D.
1992; 2000

A patient presents with a problem within his body. A physician evaluates his problem, afterwhich he comes up with a diagnosis and its recommended treatment.

If the diagnosis is a surgical disease, then the primary treatment is an operation. If the diagnosis is equivocal, the physician may elect to do a diagnostic procedure which may also be considered an operation.

An operation can be defined as diagnostic or therapeutic procedure performed with the use of instruments entering or touching directly the human body.

A venipuncture, an insertion of a tube through the nose into the stomach or a catheter through the urethra into the bladder, and an insertion of a fiberoptic scope through the anus are all considered operations done either for diagnostic or therapeutic purpose or both.

Opening the abdominal and thoracic cavities and first, exploring and then removing some organs is an operation with both diagnostic and therapeutic intent.

A chest x-ray, which uses a machine but which does not touch the human body directly is not an operation. The same is true with radiotherapy.

The words “surgery” and “operation” are often used interchangeably. Oftentimes too, the words “surgery” and “operation”, when used, refer to the therapeutic rather than to the diagnostic procedures.

An operation has been described as minor and major. However, up to now, there is no universal agreement as to the criteria of classification. What could be a major operation to some surgeons may be a minor one to others. Some surgeons have said that there is no such thing as minor surgeries but only minor surgeons. Every operation is a major activity not only from the point of view of the surgeons but also from that of the patients, especially those who are going to have it for the first time in their life. In the absence of a universal agreement, for practical purpose, major operations are those procedures which are extensive in magnitude, particularly in the amount of tissue or organs removed or repaired.

Once a decision is made that a patient needs an operation, either for diagnosis or treatment, the physician should consider the following as he discusses the plan with the patient or his guardian.

1. Timing of the operation (whether stat or now, as soon as possible, anytime, or at a specific time in the future; whether emergency or elective)
2. Use of anesthesia (yes or no; if yes, local, regional or general anesthesia)
3. Where to perform the operation (operating room, clinics, or in patient’s room)
4. Inpatient or outpatient basis (patient needs to be confined in the hospital or not)
5. Potential complications of the operation
6. Expenses

Before an operation is instituted, a physician must get an informed consent from the patient or his guardian. Beside the informed consent, he must do some preparations before the operation. These preparations constitute what is known as the preoperative care.

Preoperative care starts right after a patient has given the consent for the proposed operation to be performed. The preoperative care comes in two forms. One is preparing the patient for operation. This includes the allayance of fear and the proposed operation. Examples of the latter are transfusing blood in an anemic patient and hydrating a dehydrated patient prior to the operation.

The second form of preparation is readying materials needed for the performace of the operation or preparing for the operation itself. Examples are readying special sutures and instruments that are needed in the operation.

The operative procedures may be diagnostic or therapeutic. There are as many types of diagnostic and therapeutic oeprative procedures as there are patients needing these procedures.

Basically, however, diagnostic and therapeutic procedures are usually of the following types:

Diagnostic procedures

1. Endoscopy
2. Biopsy
3. Exploration

Therapeutic procedures

1. Repair (as of lacerated wounds)
2. Removal (as of breast cancer)
3. Control of bleeding (as from lacerated inferior vena cava)
4. Drainage (as of abscess)
5. Cleansing and debridement (as of third-degree burns)

Below is a chronological list of steps that are usually done in an abdominal operation that starts with exploration and that is performed under general anesthesia:

1. Anesthesia
2. Positioning of the patient (supine)
3. Preparing and draping of the operative field
4. Incision
5. Exploration or intraoperative assessment
6. Operative procedures
7. Hemostasis
8. Instrument and sponge count
9. Closure of incision
10. Dressing

Below is another chronological list of steps this time of an excision of a sebaceous cyst on the nape done under local anesthesia:

1. Positioning of the patient (prone)
2. Preparing and draping of the operative field
3. Anesthesia
4. Incision
5. Intraoperative assessment
6. Operative procedures
7. Hemostasis
8. Correct instrument and sponge count
9. Closure of incision
10. Dressing

Analysing the two lists above, one can see some variations in the chronology of steps. The basic procedures or steps are, however, the same.

After operation comes the postoperative care. The postoperative care starts right after the last act of a surgical procedure. It consists essentially of two things. One is providing the needs of the patient after the operation such as analgesics, nutrition, fluids and electrolytes and care of operative wounds. The other is monitoring for complications that may occur after the operation.

The relationship among the operation, its preoperative preparations and its postoperative care is such that the three are equally important. All are required for the successful outcome of an operation.

A physician who performs an operation must know how to prepare a patient for the operation. He must know how to pperform the operation. He must also know how to take care of the patient after an operation: If all the three requirements are present, a successful operation is to be expected.

ILLUSTRATIVE CASE

A 50-year-old male was brought into the emergency room because of a gunshot wound on the abdomen. On examination, the vital signs were normal. The abdomen was very tender and rigid.

The point of entry of the bullet was at the umbilicus and the point of exit at the left side of the back.

The physician at the emergency room made a diagnosis of acute surgical abdomen secondary to gunshot wound.

A consent for emergency operation was obtained. During this time an intravenous line was established and blood extracted for blood typing. An antibiotics was given intravenously.

The patient was brought immediately to the operating room. An anesthesiologist intubated the patient and administered general anesthesia. The patient was maintained on a supine position. The abdomen was prepped with antiseptic solution and later draped with sterile towels and linens. A long vertical midline incision was performed to open the abdomen.

Inside the abdomen, 500 cc of blood was seen. There were multiple perforations of the small bowels. With these findings, the surgeon decided to resect the segment of the small bowel containing the multiple perforations. After resection, an anastomosis was done to re-establish the intestinal continuity. Copious lavage of the peritoneal cavity was done. After a correct count of instruments and sponges was reported by the nurse, the abdominal incision was closed.

After the operation, the patient was given analgesics, antibiotics and intravenous fluids. The urinary catheter was removed on the 1st day postop. Diet was given on the 2nd day. Abdominal stitches were removed on the 7th day. Thereafter, the patient was discharged.

The case cited illustrates the following:

1. The decision to operate came after a diagnosis of a surgical disease.

2. The operation was intended to be both diagnostic and therapeutic.

3. It was decided that the operation be done right away at the operating room.

4. Consent was gotten before the operation.

5. Preoperative care consisted of establishment of intravenous lines, blood typing, antibiotics, and insertion of urinary catheter.

6. Anesthesia was given before the operation.

7. An intraoperative evaluation or diagnosis was made before doing the specific operative procedures.

8. The operative procedures done were essentially repair and lavage.

9. Postoperative care consisted of analgesics, antibiotics, intravenous fluids, nutrition, care of the urinary catheter and the abdominal wounds.

10. Postoperative care also consisted of monitoring for complications.

ROJ@16jan27

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