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14 - Caring for surgical patients: complications and communication
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- By Douglas M. Bowley, Royal Centre for Defence Medicine, Birmingham
- Edited by Andrew Kingsnorth, Douglas Bowley
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- Book:
- Fundamentals of Surgical Practice
- Published online:
- 03 May 2011
- Print publication:
- 17 March 2011, pp 230-247
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Summary
‘Every surgeon carries about him a little cemetery, in which from time to time he goes to pray. A cemetery of bitterness and regret, of which he seeks the reason for certain of his failures.’
La Philosophie de la Chirurgie. René Leriche, 1879–1955Introduction
Surgery creates a unique relationship between patient and practitioner. The impact of serious illness, particularly cancer, and the surgery required to treat it may impose lifelong physical and psychological burdens. These consequences are unlikely to be confined to the individual, as the patient's family and even wider society may be affected.
Establishment and maintenance of trust and the relationship of care between a surgeon and his or her patients facilitates the necessary physical and psychological transitions after major surgery. Optimal outcomes depend on this relationship as well as good preoperative preparation, optimum surgery and meticulous postoperative management.
Outcomes after surgery are influenced by:
preoperative physiological status
operative severity and
the provision of appropriate care.
Surgeons can minimize the deleterious effects of the surgical insult by careful preoperative planning, meticulous intraoperative technique and by accurate postoperative care.
Preoperative physiological status
Preoperative co-existing medical problems translate into increased operative risk. The simplest tool to assess patient risk factors is the American Association of Anesthetists (ASA) scale. This is a subjective assessment of the patient's operative risk based on the presence and severity of co-existing medical problems, which are detected by routine history and physical examination. Increasing ASA grade correlates with increased risk of postoperative complications.
3 - Postoperative management
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- By Douglas M Bowley, Department of Colorectal Surgery, John Radcliffe Hospital, Headington, Oxford, UK
- Edited by Andrew N. Kingsnorth, Derriford Hospital, Plymouth, Aljafri A. Majid
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- Book:
- Fundamentals of Surgical Practice
- Published online:
- 15 December 2009
- Print publication:
- 27 April 2006, pp 39-49
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Summary
INTRODUCTION
Outcomes after surgery are influenced by:
preoperative physiological status,
operative severity,
the provision of appropriate care.
Surgeons can minimize the deleterious effects of the surgical insult by careful preoperative planning, meticulous intraoperative technique and by accurate postoperative care.
Preoperative Physiological status
Preoperative co-existing medical problems translate into increased operative risk. The simplest tool to assess patient risk factors is the American Society of Anesthetists (ASA) scale. This is a subjective assessment of the patient's operative risk based on the presence and severity of co-existing medical problems, which are detected by routine history and physical examination.
The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) was developed in 1991. POSSUM variables include physiological markers and other factors related to operative severity. These variables have been tested extensively and have resulted in a central database of over 200,000 patients. POSSUM scoring has been used to predict the outcome of patients undergoing a broad range of operations and has been recognized as being the most appropriate available score for assessing risk in surgical patients. However, POSSUM over-predicts mortality for those patients at the low-risk end of the spectrum. The Portsmouth group revised the scoring and the so-called P-POSSUM is now widely used.
Operative severity
Surgery (or trauma from injury) has been shown to result in immune suppression and organ failure is the leading cause of death in surgical patients.
13 - Lower gastrointestinal surgery
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- By Douglas M Bowley, Department of Colorectal Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK, Christopher Cunningham, Department of Colorectal Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK
- Edited by Andrew N. Kingsnorth, Derriford Hospital, Plymouth, Aljafri A. Majid
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- Book:
- Fundamentals of Surgical Practice
- Published online:
- 15 December 2009
- Print publication:
- 27 April 2006, pp 249-263
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Summary
SURGICAL ANATOMY
Accurate understanding of the pelvic anatomy is critical to achieving good oncological and functional outcomes after rectal excision. Heald et al. (1998) in Basingstoke introduced the concept of total mesorectal excision during the 1980s. Total Mesorectal Excision (TME) consists of separate high ligation of the inferior mesenteric vessels to define the proximal limits of the lymphatic clearance, followed by rectal mobilisation with sharp dissection under direct vision in the avascular plane outside the mesorectum excising the entire mesorectum and leaving the autonomic nerve plexuses intact. This surgical innovation has been shown to reduce local recurrence dramatically, while maximising the chances of sphincter-preserving surgery.
Permanent impotence in men has been reported to be almost universal in some series of abdominoperineal excisions of rectum and occurs in up to half of all men after anterior resection of the rectum for rectal cancer. The incidence of permanent bladder denervation after rectal excisional surgery has been reported to be up to 19% in some series. The presumed mechanism for sexual and urinary dysfunction is damage to the pelvic autonomic parasympathetic and/or sympathetic nerves during surgery.
The risk of sympathetic nerve damage occurs in the abdomen during ligation of the inferior mesenteric artery pedicle, and high in the pelvis during initial posterior rectal dissection adjacent to the large hypogastric nerves.