Before a major operation

A patient is much more likely to withstand major surgery successfully if he is as fit as he can be to begin with. So do all you can to get him into the best possible condition first. You will not be able to do a thorough ''workup', but there are things you can do. For example, if you find that he is anaemic, malnourished, or tuberculous, and his operation is not urgent, treat him. Severe malnutrition will greatly reduce his ability to withstand the operation. Above all, don't operate on him while he is still dehydrated[md]this at least you should be able to correct (A 15.3).

Assess his need for surgery, the best time for it, and the risks it will involve. If a particular procedure would be too much for him, you will have to ask yourself if there is a lesser alternative which you could do under local anaesthesia, and what will happen if you do nothing? If there is a choice of procedures, do the simplest and safest one, for example, the insertion of a drainage tube rather than removing his gall bladder (13.17).

Follow these rules: (1) Don't start an operation without thinking it through step by step before you start. (2) Monitor him closely for 48 hours after any emergency or major operation. (3) Prevent the aspiration of stomach contents (A 16.1), and treat respiratory depression (A 3.4) immediately. (4) The most common postoperative complications are respiratory, and the answer to most of them is vigorous coughing (9.11). (5) Learn the basic principles of fluid therapy (A 15.1 to 15.5). (6) The operation may be routine to you, but it is sure to be a major event in his life, so try to establish a good relationship with him and his family. Tell him why you are operating, and give him some idea of what to expect afterwards[md]how much pain he will have, and when he will recover. If you might have to make a colostomy, discuss this with him before you operate. If you promise to close it eventually, be sure to do so.

Most of the major operations you do are likely to be abdominal ones, so here is the routine preoperative care for a patient who is to have a laparotomy.

Fig. 9-1 THE ANTERIOR ABDOMINAL WALL. A, common abdominal incisions. B, the ''ultimate incision', if you want an extensive exposure. C, the anatomy of the anterior abdominal wall. C, after Maingot R, ''Abdominal Operations' (4th edn 1961), Fig. 1, HK Lewis, with kind permission.

PREOPERATIVE PREPARATION HISTORY AND EXAMINATION. What previous illnesses has the patient had? Is he taking any drugs? Is he sensitive to anything, particularly to streptomycin, sulphonamides, penicillin, or chloroquin?

Assess his degree of wasting. Ask about a cough, fever, chest pain, dyspnoea, and smoking. How fit is he? Can he climb hills, or do a day's work in the fields? Can he step up and down off a chair for half a minute without becoming short of breath? Or, can he hold his breath for 20 seconds? Look for signs of anaemia. Feel the strength of his grip; this is a good predictor of surgical risk in men, less so in women.

SPECIAL TESTS. Measure his haematocrit or haemoglobin. Test his urine for albumin and sugar, and examine its deposit. This will exclude any serious disease of his urinary tract, and help you to diagnose renal colic, which may present as an acute abdomen. Test his blood group, and if necessary cross-match blood for him. Remember the risk of HIV. If you suspect heart or lung disease, take a chest X-ray.

ASSOCIATED DISEASE. If necessary, and if time allows, try to improve his general health, especially his nutrition and hydration. Look for tuberculosis and chronic renal disease.

If he is malnourished, especially if he is a child, and his disease permits, feed him by mouth or by nasogastic tube, even for as short a period as two weeks before you operate. If he is anorexic, feeding him will be difficult. He may tolerate nasogastric feeding (9.10, 58.11).

If he is febrile, consider the possibility of malaria or typhoid fever, in addition to the possible surgical causes of fever.

If he is anaemic, consider the urgency of the operation in relation to the severity of his anaemia. Most ''routine' operations can be done with a haemoglobin as low as 80 g/l. It it is 60 or 70 g/l, only do urgent procedures. For example, a woman with haemoglobin of 30 g/l who is bleeding slowly from an ectopic pregnancy can be transfused overnight with 20 ml/kg of blood (from her abdominal cavity if necessary) and given 1 mg/kg of frusemide. If an operation is less urgent, for example a hysterectomy for chronic anaemia due to fibroids, transfuse her 2 or 3 days before you operate. For nonurgent surgery you can take a unit of blood 4 weeks and 2 weeks before a planned major operation, and store them.

If a patient has jaundice, it will greatly increase the risks of surgery, but not operating may be even more dangerous. Give him parenteral vitamin K[,1] for a few days preoperatively. Exclude hepatitis first, especially the acute stage, when anaesthesia can be dangerous.

If he is producing sputum, give him chest physiotherapy and a course of antibiotics prior to surgery if possible. Anaesthetize him appropriately, using local or regional blocks where possible (A 17.8). If he has a common cold, cancel anything but an emergency operation.

CHEST PHYSIOTHERAPY before and after the operation will reduce the risk of lung complications[md]see Section 9.11.

SKIN PREPARATION. If he is very dirty, wash the operation site several times. If he has pustules, boils, or eczematous patches near the site of your proposed incision, treat them before you operate. Bacteria from them may infect the wound, so consider delayed primary closure (9.8).

NASOGASTRIC SUCTION. Insert a nasogastric tube before all stomach or gut operations. The danger of aspiration pneumonitis is even greater if he has intestinal obstruction or ileus.

PERIOPERATIVE ANTIBIOTICS may be lifesaving[md]see Section 2.9.