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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!