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

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

Try some related OSCE stations!

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2. Post-operative complication
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