Discussion about surgery

Introduction

• Wash hands; Introduce self; ask Patient’s name, DOB and what they like to be called; Explain what you propose to do
• Confirm the operation that is planned
• Ask about what they know so far
• Explore concerns and ask about anything specific they want to know

Before the operation

• Pre-operative assessment
  • Aims to assess medical fitness for an operation/anaesthetic; ascertain mobility, independence, who is at home, medications and allergies
  • Involves a history and physical examination
  • Will confirm which medications to stop and when
• Pre-operative investigations
  • May include: blood tests, chest x-ray, ECG, echocardiography, cardiopulmonary exercise testing
• There may be special pre-operative measures which the patient will be told about if needed, e.g. bowel prep
• The timing of admission will be discussed, e.g. whether on the morning of or evening before surgery 
• Consent will be taken by a surgeon prior to theatre
  • The surgeon will discuss the procedure, the risks and benefits
  • A consent form will need to be signed (but the patient can change their mind at any time)
  • The patient will not be pressured
• The patient should be instructed about fasting (when to stop eating and drinking)
  • Usually ‘2-6 rule’ = no food for 6 hours pre-op; can have clear fluids up to 2 hours pre-op; nothing thereafter
• If the operation is on one side (left or right), then the correct side will be ‘marked’ with a black arrow 

During the operation 

• The patient will be taken to the anaesthetic room by a theatre nurse
• Relatives may stay with the patient until this point
• The patient will then meet the anaesthetist who will insert a cannula to give an anaesthetic
• If a general anaesthetic is required, the patient will be intubated, e.g. ‘you will have a tube through your mouth to control breathing during the operation. You will not remember this but you may have a sore throat afterwards. It will be taken out when you are waking up.’
• The operation will then be performed – offer details about the specific operation

Types of anaesthetic

Type	Detail	Examples where it may be used
General	Medication that is inhaled or injected to induce a reversible loss of consciousness	Many operations
Spinal	Needle is inserted into the lower back and a local anaesthetic is injected into the cerebrospinal fluid (the fluid in the subarachnoid space that surrounds the spinal cord) to numb the lower body	Operations below the umbilicus, e.g. lower limb surgery, pelvic surgery, C-section/childbirth
Epidural	Catheter is inserted into the back and a local anaesthetic is injected as required into the epidural space (the outermost part of the spinal cord) to numb the lower body.	Epidural is usually performed for longer operations or when analgesia is required post-operatively
Nerve block	Local anaesthetic injected around the nerve(s) that supplies the area being operated on	Procedures on hands, arms, feet, legs or face
Local	Local anaesthetic injected directly into the area that is being operated on	Minor procedures on small areas

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

After the operation

• The patient will wake up in the recovery area
• There may be tubes that were inserted in theatre, e.g. catheter, drains
• Pain control – there are a variety of options that may be used:
  • Intravenous (patient-controlled analgesia) – ‘you will be given a button that you can press whenever you want pain relief’
  • Oral
  • Local wound catheters – ‘local anaesthetic may be directly injected into the site by a small tube’
• Depending on the type of surgery, there may be limitations on what the patient is allowed to eat/drink for a period afterwards
• VTE prophylaxis: the patient will usually be given a heparin (‘a small injection in the skin of your tummy each day’) and may be asked to wear compression stockings to prevent blood clots 
• Physiotherapy: the patient will be seen by physiotherapists to build up their mobility after the operation
• Occupational therapy: if required, the patient will be assessed by therapists who will help arrange care or modify their home to help them cope after the operation 

Risks/complications

These must be explained using lay terms. Try not to scare the patient. Explain most complications are rare and how the risk of complications is minimised.

Generic risks

• Anaesthetic complications (e.g. arrhythmias, hypo-/hypertension, hyperthermia, breathing problems, MI/stroke, allergy, teeth/lip/tongue damage, sore throat)
• Bleeding/haematoma
• Damage to nearby structures/organs
• Infections: local (wound/surgical site) or systemic (chest/UTI/sepsis)
• Venous thromboembolism (DVT/PE)
• Pain
• Fluid collections

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