Download INDICATION OF SURGERY

DEFINITION OF SURGERY
Any preventive, diagnostic or
therapeutic intervention which
directly or indirectly disrupts
and/or restores the integrity of
the body/organ
No single definition exists!
Natura Sanat (nature heals)
PREREQUISITES OF SURGERY
Proper patient
- adequate indication of surgery
(lack of contraindications)
- written, informed consent
Proper timing
- wait for the best condition of the patient
(depends on the urgency of the case)
- preferably operate when the staff is in the
best condition
Proper circumstances
- all the personal and material conditions of
a successful surgery are met – no time
constraints
THE ROLE OF THE SURGEON
Theoretical and practical knowledge
- knowledge of the possible treatment options
- assessment of the risk/benefit ratio
- experience – beyond the learning curve
- honor your limits – personal, material, etc.
- audition of the results – learn from the mistakes
Knowledge of the patient
- history
- examination
- disease course
- think out of the box – are there better non-surgical
treatments?
Manual abilities
INDICATION OF SURGERY
Vital
Can only be treated with immediate/urgent surgery,
timing cannot be chosen
- major bleeding, ileus, perforation, appendicitis
Absolute
Can only be treated with surgery, can be scheduled
- tumors, symptomatic hernias or gall stones
Relative
May be treated by non-surgical means /
no harm done without surgery
- asymptomatic hernia or gall stones, GERD
INDICATION OF SURGERY
Social/cosmetic
No harm done without surgery, intervention is
peformed upon the request of the patient
- breast augmentation, bariatric surgery
Prophylactic
Aims to prevent a later disease or medical condition
- FAP, „negative” appendectomy
Diagnostic
Aims to diagnose a disease or medical condition
- lymph node biopsy, diagnostic laparoscopy
INDICATION-CONTRAINDICATION
- To make the decision is at least as important as the surgery itself
- Carefully consider and synthetise all the available data – decision can lead
to death or life-threatening complications
- Sometimes it is easier to operate than not to operate
- Decision requires adequate knowledge of the disease, the patient, the
nature of the intervention and the surgeon’s expertise and limits
- Decision is individual - „me or my relative” test
- Decision is not final! Applies only to the given condition of the patient at
the given time in the given institute
ESTABLISHING THE INDICATION
Factors related to the indication of surgery
- Diagnosis
- Symptoms (if no exact diagnosis is known)
- Timing of the surgery (immediate/urgent/scheduled)
- Operative load
- Operative tolerance
- Operability – technical, medical, oncological
- Alternative treatment modalities
- Prognosis
- Personal/material/(financial) circumstances
- Patient consent
Always consider cost/benefit ratio!
QUESTION OF OPERABILITY
Medical/anesthesiological
- Laboratory parameters (ions [K!], blood sugar, Hgb, INR)
- Age – decreased significance!
- General conditions, co-morbidities
- Drugs (e.g. Warfarin, antidepressants)
- Allergies, issues with anesthesia/intubation
Surgical
- Technical (depends on surgeon and institute)
- Oncological (curative intent/palliation)
Operability depends on
- the nature of intervention
- the type of indication
Nil Nocere (don’t do harm)!
CONTRAINDICATION OF SURGERY
Absolute contraindications are less
- Most people can be anesthetized and operated
- Improved(minimally invasive) operative techniques
- Basically there is no contraindication in vital cases!
Contraindication applies to the given patient
at the given time
- Patient’s condition can be improved
- Patient’s condition can deteriorate
- Can be treated with another treatment modality
- Other surgeon, other institute can offer
better/alternative methods – „second opinion”
No patient consent
- Depends on the age and condition of the patient and
the type of indication
CONTRAINDICATION OF SURGERY
Absolute contraindication
- Moribund state, coma
- Severe cardial failure
- Hemorrhagic shock (without surgical cause:
e.g. gastrointestinal bleeding)
- Severe metabolic or hemostatic imbalance
- Lack of written informed consent (except in life-threatening cases)
Relative contraindications
- Age
- Pregnancy (depends on trimester)
- Co-morbidities
- Confirmed, end-stage incurable disease
- Better alternative treatment modalities
- Technical reasons (instruments, staff, circumstances, etc.)
ASSESSMENT OF SURGICAL RISK
Before every surgery: lab tests, chest X-ray, anesthesiologic
examination + special investigations if necessary
Score systems to assess the condition of the patient/risk factors
- POSSUM, APACHE, RANSOM, ASA, etc.
- Only general recommendations, not applicable to every patient
- Evidence-based surgery ↔ „the art of surgery”
Assessment of the general condition of the patient
- Everyday activity of the patient = cardiorespiratoric reserve, nutrition,
diabetes, age (biologic ↔ chronologic), emotional and social conditions
Consultations
- Anesthesiology, specialists (cardiology, ECHO, spirometry, etc.)
PREPARATION FOR SURGERY
Well before the surgery
Factors that can be modified
- Diabetes, heart failure (pacemaker)
- Blood pressure
- Hematologic diseases (history)
- Nutritional state (obesity, cachexy)
- Infectious sources (teeth, ulcers, etc.)
- Certain medication (Warfarin, platelet adhesion
inhibitors, tricyclic antidepressants)
Factors that cannot be modified
Age, sex, chronic diseases
PREPARATION FOR SURGERY
Right before the surgery
Per os feeding
- Nothing per os from the night of the surgery
Bowel preparation
Blood volume resuscitation
Metabolic balance
- DM, renal functions
Antibiotics
Thrombosis prophylaxis
- should be started before the surgery
Thorough cleaning (+surgical skin preparation)
Emotional, psychological preparation
CHANGES DURING THE LAST DECADES
Unerring surgeon „demigods”, master
craftsmen, „above anybody else”
Intimidated , uninformed patients without
choices and questions
PAST
„Master-slave relationship”
PRESENT
or
FUTURE
Professionally trained, specialized doctors,
standards and guidelines, evidence-based
surgery
Treats the patient as partner
Health-conscious, „educated” patients, who
respect the surgeon, but expect the best
available treatment and want choices
SOCIAL SETTING
Law conscious patients (and eager
lawyers)
- Litigation ↔ defensive medicine (proper
documentation) – legal knowledge
No more myth, educated patients
- Institutes must publish results
- Commonly available knowledge (BEWARE the
half-educated patient)
- Medical-legal advisory homepages, boards
Patient rights offices, specialized
lawyers
Financial pressure
- Aging society
- High-cost, sophisticated diagnostics
- Evidence based surgery – guidelines has to be
followed
PATIENT RIGHTS
Right for:
FOR MEDICAL TREATMENT
FOR HUMAN DIGNITY
FOR GETTING ALL INFORMATION RELATED
THEMSELVES
SELF-DETERMINATION
PATIENT RIGHTS
FOR REJECTION ANY KIND OF MEDICAL
TREATMENT
FOR MEDICAL SECRECY
TO RECOGNISE ALL DATA CREATED DURING
THEIR TERATMENT
FOR HAVING CONTACT PERSONS
MALPRACTICE (Who wants to be a millionaire?)
- Around 300 medical malpractice claims annually in
Hungary
- The number is doubled every second year
- Only 3 out of 10 reaches court stage
- The amount paid to claimants is 10-fold (average:
617.000 dollars in 2010 in the USA)
- Most frequently sued professions: gynecology,
surgery, plastic surgery, heart surgery, etc.
Most frequent causes:
- Inadequate communication
- Manners
- Unwanted results/outcome
…
- Actual profession mistakes
INFORMED CONSENT
„…right for getting all information”
Patient counseling, informed consent
- One of the most common causes of malpractice
claims is inadequate counseling
- Must be detailed and tailored to the surgery
and the patient
- The patient has to understand it
- Must be signed (also the refusal must
be signed)
- Interactive (should be signed with the patient)
- Not only surgeries (every intervention must
be signed by the patient: transfusion,
endoscopy, anesthesia, etc.)
- Minors and mentally disabled: GUARDIAN
- No consent is necessary: vital indication,
life-threatening condition, unconscious patient if
delay may lead to health deterioration
INFORMED CONSENT
What are the elements of
full informed consent?
The most important goal of informed consent is that
the patient have an opportunity to be an informed
participant in his health care decisions. It is
generally accepted that complete informed consent
includes a discussion of the following elements:
- the nature of the decision/procedure
- reasonable alternatives to the proposed
intervention
- the relevant risks, benefits, and uncertainties
related to each alternative
- assessment of patient understanding the
acceptance of the intervention by the patient
SALUS AEGROTI SUPREMA LEX!