4 5947406296134190606

Textbook of Surgery
Textbook of
Surgery
EDITED BY
Julian A. Smith
MBBS, MS, MSurgEd, FRACS, FACS, FFSTRCSEd, FCSANZ, FAICD
Head, Department of Surgery (School of Clinical Sciences at Monash Health), Monash University
Head, Department of Cardiothoracic Surgery, Monash Health
Editor‐in‐Chief, ANZ Journal of Surgery
Andrew H. Kaye AM
MBBS, MD, FRACS
Head, Department of Surgery, The University of Melbourne
Christopher Christophi AM
MBBS (Hons), MD, FRACS, FRCS, FACS
Head of Surgery (Austin Health), The University of Melbourne
Wendy A. Brown
MBBS (Hons), PhD, FRACS, FACS
Head, Department of Surgery (Central Clinical School, Alfred Health), Monash University
Director, Centre for Obesity Research and Education (CORE), Monash University
FOURTH EDITION
This edition first published 2020 © 2020 by John Wiley & Sons Ltd
Edition History
1e (1997); 2e (2001); 3e (2006) Blackwell Publishing Ltd.
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Library of Congress Cataloging‐in‐Publication Data
Names: Smith, Julian A., editor. | Kaye, Andrew H., 1950– editor.
Title: Textbook of surgery / edited by Julian A. Smith, MBBS, MS, MSurgEd, FRACS, FACS, FFSTRCSEd, FCSANZ,
FAICD Head, Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Head,
Department of Cardiothoracic Surgery, Monash Health, Editor-in-Chief, ANZ Journal of Surgery, Andrew H. Kaye,
AM, MBBS, MD, FRACS, Head, Department of Surgery, The University of Melbourne, Christopher Christophi, AM,
MBBS (Hons), MD, FRACS, FRCS, FACS, Head of Surgery (Austin Health), The University of Melbourne, Wendy A.
Brown, MBBS (Hons), PhD, FRACS, FACS, Head, Department of Surgery (Central Clinical School, Alfred Health),
Monash University Director, Centre for Obesity Research and Education (CORE), Monash University.
Other titles: Surgery
Description: Fourth edition. | Hoboken, NJ : Wiley-Blackwell, 2020. | Includes bibliographical references and index.
Identifiers: LCCN 2019030070 (print) | LCCN 2019030071 (ebook) | ISBN 9781119468080 (paperback) |
ISBN 9781119468172 (adobe pdf) | ISBN 9781119468165 (epub)
Subjects: LCSH: Surgery.
Classification: LCC RD31 .T472 2020 (print) | LCC RD31 (ebook) | DDC 617–dc23
LC record available at https://lccn.loc.gov/2019030070
LC ebook record available at https://lccn.loc.gov/2019030071
Cover image: © gchutka/Getty Images
Cover design by Wiley
Set in 9/11.5pt Sabon by SPi Global, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
Contents
Contributors, viii 16 Peptic ulcer disease, 133

Preface, xiii Paul A. Cashin and S.C. Sydney Chung
Acknowledgements, xiv 17 Gastric neoplasms, 143
John Spillane
Section 1 Principles of Surgery 18 Obesity and bariatric surgery, 151
1 Preoperative management, 3 Yazmin Johari and Wendy A. Brown
Julian A. Smith
2 Assessment of surgical risk, 13 Section 3 Hepatopancreaticobiliary Surgery
Benjamin N.J. Thomson 19 Gallstones, 163
Arthur J. Richardson
3 Anaesthesia and pain medicine, 19
David Story 20 Malignant diseases of the hepatobiliary
system, 173
4 Postoperative management, 25
Thomas J. Hugh and Nigel B. Jamieson
Peter Devitt
21 Liver infections, 191
5 Surgical techniques, 35
Vijayaragavan Muralidharan, Marcos V. Perini
Benjamin N.J. Thomson and David M.A. Francis
and Christopher Christophi
6 Management of surgical wounds, 45
22 Pancreatitis, 199
Rodney T. Judson
Peter S. Russell and John A. Windsor
7 Nutrition and the surgical patient, 49
23 Pancreatic tumours, 209
William R.G. Perry and Andrew G. Hill
David Burnett and Mehrdad Nikfarjam
8 Care of the critically ill patient, 57
24 Portal hypertension and surgery on the patient
Jeffrey J. Presneill, Christopher MacIsaac
with cirrhosis, 219
and John F. Cade
Michael A. Fink
9 Surgical infection, 65
Marcos V. Perini and Vijayaragavan Section 4 Lower Gastrointestinal Surgery
Muralidharan 25 Principles of colorectal and small bowel
10 Transplantation surgery, 75 surgery, 229
Michael A. Fink Ian Hayes
11 Principles of surgical oncology, 87 26 Physiology of small and large bowel: alterations
G. Bruce Mann and Robert J.S. Thomas due to surgery and disease, 237
12 Introduction to the operating theatre, 93 Jacob McCormick and Ian Hayes
Andrew Danks, Alan C. Saunder 27 Small bowel obstruction and ischaemia, 243
and Julian A. Smith Ian Hayes and the late Joe J. Tjandra
13 Emergency general surgery, 109 28 The appendix and Meckel’s diverticulum, 249
Benjamin N.J. Thomson and Rose Shakerian Rose Shakerian and the late Joe J. Tjandra
29 Inflammatory bowel disease, 255
Section 2 Upper Gastrointestinal Surgery Susan Shedda, Brit Christensen and
14 Gastro‐oesophageal reflux disease and hiatus the late Joe J. Tjandra
hernias, 115 30 Diverticular disease of the colon, 267
Paul Burton and Geraldine J. Ooi Ian Hastie and the late Joe J. Tjandra
15 Tumours of the oesophagus, 123 31 Colorectal cancer, 273
Ahmad Aly and Jonathan Foo Ian T. Jones and the late Joe J. Tjandra
v
vi Contents
32 Large bowel obstruction, 285 Section 11 Orthopaedic Surgery

Raaj Chandra 50 Fractures and dislocations, 457
33 Perianal disorders I: excluding sepsis, 293 Peter F. Choong
Ian Hayes and Susan Shedda 51 Diseases of bone and joints, 465
34 Perianal disorders II: sepsis, 301 Peter F. Choong
Ian Hayes and the late Joe J. Tjandra
Section 12 Neurosurgery
Section 5 Breast Surgery 52 Head injuries, 483
35 Breast assessment and benign breast Andrew H. Kaye
disease, 309 53 Intracranial tumours, infection and
Rajiv V. Dave and G. Bruce Mann aneurysms, 493
36 Malignant breast disease and surgery, 317 Andrew H. Kaye
Rajiv V. Dave and G. Bruce Mann 54 Nerve injuries, peripheral nerve entrapments
and spinal cord compression, 511
Section 6 Endocrine Surgery Andrew H. Kaye
37 Thyroid, 331
Jonathan Serpell Section 13 Vascular Surgery
38 Parathyroid, 339 55 Disorders of the arterial system, 527
Jonathan Serpell Raffi Qasabian and Gurfateh
39 Tumours of the adrenal gland, 345 Singh Sandhu
Jonathan Serpell 56 Extracranial vascular disease, 537
Raffi Qasabian and Gurfateh Singh Sandhu
Section 7 Head and Neck Surgery 57 Venous and lymphatic diseases
40 Eye injuries and infections, 353 of the limbs, 545
Helen V. Danesh‐Meyer Hani Saeed and Michael J. Grigg
41 Otorhinolaryngology, 359 58 Endovascular therapies, 553
Stephen O’Leary and Neil Vallance Timothy Buckenham
42 Tumours of the head and neck, 369
Rodney T. Judson Section 14 Urology
59 Benign urological conditions, 565
Section 8 Hernias Anthony J. Costello, Daniel M. Costello and
43 Hernias, 381 Fairleigh Reeves
Roger Berry and David M.A. Francis 60 Genitourinary oncology, 577

Homayoun Zargar and Anthony J. Costello

Section 9 Skin and Soft Tissues
44 Tumours and cysts of the skin, 397 Section 15 Cardiothoracic Surgery
Rodney T. Judson 61 Principles and practice of cardiac surgery, 587
45 Soft tissue tumours, 403 James Tatoulis and Julian A. Smith
Peter F. Choong 62 Common topics in thoracic surgery, 603
46 Infection of the extremities, 415 Julian A. Smith
Mark W. Ashton and David M.A. Francis
47 Principles of plastic surgery, 423 Section 16 Problem Solving
Mark W. Ashton 63 Chronic constipation, 617
Kurvi Patwala and Peter De Cruz
Section 10 Trauma 64 Faecal incontinence, 625
48 Principles of trauma management, 431 Andrew Bui
Scott K. D’Amours, Stephen A. Deane and 65 Rectal bleeding, 633
Valerie B. Malka Adele Burgess
49 Burns, 443

66 Haematemesis and melaena, 637
Ioana Tichil and Heather Cleland Wendy A. Brown
Contents vii
67 Obstructive jaundice, 643 76 Massive haemoptysis, 707

Frederick Huynh and Val Usatoff Julian A. Smith
68 The acute abdomen, peritonitis and

77 Epistaxis, 711
intra‐abdominal abscesses, 649 Robert J.S. Briggs
Paul Cashin, Michael Levitt and 78 Low back and leg pain, 715
the late Joe J. Tjandra Jin W. Tee and Jeffrey V. Rosenfeld
69 Ascites, 659 79 Acute scrotal pain, 727

David A.K. Watters, Sonal Nagra and Anthony Dat and Shomik Sengupta
David M.A. Francis 80 Post‐traumatic confusion, 735
70 Neck swellings, 667

John Laidlaw
Rodney T. Judson 81 Sudden‐onset severe headache, 745
71 Acute airway problems, 675 Alexios A. Adamides
Stephen O’Leary 82 The red eye, 749
72 Dysphagia, 679 Christine Chen
Wendy A. Brown 83 Double vision, 757
73 Leg swelling and ulcers, 685 Christine Chen
Alan C. Saunder, Steven T.F. Chan and
David M.A. Francis Answers to MCQs, 763
74 Haematuria, 693 Index, 767
Kenny Rao and Shomik Sengupta
75 Postoperative complications, 699

Peter Devitt
Contributors
Alexios A. Adamides Andrew Bui

BMedSci, BMBS, MRCS (Edin), MD, FRACS MBBS, MSc, FRACS
Clinical Senior Lecturer, University of Melbourne Lecturer in Surgery, University of Melbourne
Neurosurgeon, Royal Melbourne Hospital Colorectal Surgeon, Austin Health
Melbourne, Victoria, Australia Melbourne, Victoria, Australia
Ahmad Aly Adele Burgess

MBBS, MS, FRACS BMedSci (Hons), MBBS, FRACS
Clinical Associate Professor of Surgery, University of Senior Lecturer in Surgery, University of Melbourne
Melbourne Head, Colorectal Surgery, Austin Health
Head, Upper Gastrointestinal Surgery, Austin Health Melbourne, Victoria, Australia
Melbourne, Victoria, Australia
David Burnett
Mark W. Ashton BSc, MBBS, FRACS
MBBS, MD, FRACS Hepatopancreaticobiliary Surgeon
Clinical Professor of Surgery, University of Melbourne John Hunter Hospital
Plastic Surgeon, Royal Melbourne Hospital Newcastle, New South Wales, Australia
Paul Burton
MBBS(Hons), PhD, FRACS
Roger Berry
Senior Lecturer in Surgery, Monash University
MBBS, FRACS
Upper Gastrointestinal Surgeon, Alfred Health
Upper Gastrointestinal and Hepatobiliary Surgeon,
Monash Health
Melbourne, Victoria, Australia John F. Cade AM
MD, PhD, FRACP, FANZCA, FCICM
Professorial Fellow, Department of Medicine, University
Robert J.S. Briggs of Melbourne
MBBS, FRACS, FACS Emeritus Consultant in Intensive Care, Royal Melbourne
Clinical Professor of Surgery, University of Melbourne Hospital
Clinical Executive Director of Otolaryngology; Head, Melbourne, Victoria, Australia
Otology and Medical Director, Cochlear Implant Clinic,
Royal Victorian Eye and Ear Hospital Paul A. Cashin
Melbourne, Victoria, Australia MBBS, FRACS
Clinical Associate Professor of Surgery, Monash
Wendy A. Brown University
MBBS (Hons), PhD, FRACS, FACS Director of General Surgery, Monash Health
Head, Department of Surgery (Central Clinical School, Melbourne, Victoria, Australia
Alfred Health), Monash University
Director, Centre for Obesity Research and Education Steven T.F. Chan
(CORE), Monash University MBBS, PhD, FRACS
Melbourne, Victoria, Australia Professor of Surgery, University of Melbourne
Upper Gastrointestinal Surgeon, Western Health
Timothy Buckenham Melbourne, Victoria, Australia
MBChB, FRANZCR, FRCR, FCIRSE, EBIR
Professor of Vascular Imaging and Intervention, Monash Raaj Chandra
University MBBS, BMed Sci, MEd, FRACS
Head, Vascular Services, Department of Imaging, Adjunct Senior Lecturer in Surgery, Monash University
Monash Health Colorectal Surgeon, Royal Melbourne Hospital
viii
Contributors ix
Christine Chen Andrew Danks

MBBS, PhD, FRANZCO MBBS, MD, FRACS
Clinical Associate Professor of Surgery, Monash University Associate Professor of Surgery, Monash University
Head, Department of Ophthalmology, Monash Health Head, Department of Neurosurgery, Monash Health
Peter F. Choong Anthony Dat

MBBS, MD, FRACS, FAOrthA, FAAHMS MBBS, MS
Professor of Surgery, University of Melbourne Urology Registrar, Eastern Health
Director of Orthopaedics, St. Vincent’s Hospital Melbourne, Victoria, Australia
Chair, Bone and Soft Tissue Sarcoma Service
Peter MacCallum Cancer Centre Rajiv V. Dave
Melbourne, Victoria, Australia MBChB, FRCSEd, MD, BSc(Hons)
Fellow in Oncoplastic Breast and Endocrine Surgery,
Britt Christensen Royal Melbourne Hospital
BSc, MBBS(Hons), MPH, FRACP Melbourne, Victoria, Australia
Head, Inflammatory Bowel Disease Unit, Department of The Nightingale Centre, Manchester University NHS
Gastroenterology, Royal Melbourne Hospital Foundation Trust
Melbourne, Victoria, Australia Manchester, UK
Christopher Christophi AM Stephen A. Deane AM

MBBS, FRACS, FACS, FRCSC, FRCSEd (ad hom),
MBBS (Hons), MD, FRACS, FRCS, FACS
FRCSThailand (Hon)
Head of Surgery (Austin Health), University of
Associate Dean, Clinical Partnerships, Macquarie
Melbourne
University, Sydney
Conjoint Professor of Surgery, University of Newcastle
Honorary Consultant Surgeon, Hunter and New
S.C. Sydney Chung
England Local Health District
MD, FRCS (Edin), FRCP (Edin)
New South Wales, Australia
Formerly Dean, Faculty of Medicine, Chinese University
of Hong Kong Peter De Cruz
Senior Consultant in Surgery, Union Hospital MBBS, PhD, FRACP
Hong Kong Senior Lecturer in Medicine, University of Melbourne
Gastroenterologist and Director, Inflammatory Bowel
Heather Cleland Disease Service, Austin Health
MBBS, FRACS Melbourne, Victoria, Australia
Director, Victorian Adult Burns Service and Plastic
Surgeon, Alfred Health Peter Devitt
Melbourne, Victoria, Australia MBBS, MS, FRCS, FRACS
Associate Professor of Surgery, University of Adelaide
Anthony J. Costello AM General and Upper Gastrointestinal Surgeon, Royal
MBBS, MD, FRACS, FRCSI (Hon) Adelaide Hospital
Professorial Fellow, University of Melbourne Adelaide, South Australia, Australia
Head, Department of Urology, Royal Melbourne Hospital
Melbourne, Victoria, Australia Michael A. Fink
MBBS, MD, FRACS
Daniel M. Costello Senior Lecturer in Surgery, University of Melbourne
MBBS, DipSurgAnat Hepatopancreatobiliary and Liver Transplant Surgeon,
Surgical Resident, St. Vincent’s Hospital Austin Health
Scott K. D’Amours Jonathan Foo

BSc, MDCM, FRCSC, FRACS, FRCS(Glasg), FACS MBChB, DipGrad(Arts), PhD, FRACS
Conjoint Senior Lecturer in Surgery, University of New Upper Gastrointestinal Surgery Fellow, Austin Health
South Wales Melbourne, Victoria, Australia
Director, Department of Trauma Services, Liverpool
Hospital David M.A. Francis
Sydney, New South Wales, Australia BSc (Med Sci), MS, MD, PhD (Arts), FRCS (Eng), FRCS
(Edin), FRACS
Helen V. Danesh‐Meyer Renal Transplant Surgeon, Department of Urology, Royal
MBChB, MD, PhD, FRANZCO Children’s Hospital, Melbourne, Victoria, Australia
Professor of Ophthalmology, School of Medicine, Visiting Professor of Surgery and Renal Transplant
University of Auckland Surgeon, Department of Surgery, Tribhuvan University
Auckland, New Zealand Teaching Hospital, Kathmandu, Nepal
x Contributors
Michael J. Grigg Andrew H. Kaye AM

AM, MBBS, FRACS MBBS, MD, FRACS
Professor of Surgery, Monash University Head, Department of Surgery, University of Melbourne
Director of Surgery, Eastern Health Neurosurgeon, Royal Melbourne Hospital
Ian Hastie John Laidlaw

MBBS, FRACS MBBS, FRACS
Senior Lecturer in Surgery, University of Melbourne Clinical Associate Professor of Surgery, University of
Colorectal Surgeon, Royal Melbourne Hospital Melbourne
Melbourne, Victoria, Australia Neurosurgeon, Royal Melbourne Hospital
Ian Hayes
MBBS, MS, MEpi, FRCS(Gen Surg), FRACS Michael Levitt
Clinical Associate Professor of Surgery, University of MBBS, FRACS
Melbourne Colorectal Surgeon, St. John of God Healthcare, Subiaco
Head, Colorectal Surgery Unit, Royal Melbourne Perth, Western Australia, Australia
Hospital
Melbourne, Victoria, Australia Jacob McCormick
BMedSci, MBBS, FRACS
Andrew G. Hill Colorectal Surgeon, Royal Melbourne Hospital and Peter
MBChB, MD, EdD, FRACS, FACS MacCallum Cancer Centre
Professor of Surgery, University of Auckland Melbourne, Victoria, Australia
Colorectal Surgeon, Middlemore Hospital
Auckland, New Zealand Christopher MacIsaac
MBBS (Hons), PhD, FRACP, FCICM
Thomas J. Hugh Associate Professor in Medicine
MD, FRACS Director, Intensive Care Unit, Royal Melbourne Hospital
Professor of Surgery, University of Sydney Melbourne, Victoria, Australia
Head, Upper Gastrointestinal Surgery Unit, Royal North
Shore Hospital Valerie B. Malka
Sydney, New South Wales, Australia MBBS, FRACS, MIPH, MA
Senior Lecturer in Surgery, University of New South Wales
Frederick Huynh General and Trauma Surgeon, Deputy Director of
BSc(Hons), MBBS(Hons), FRACS Trauma, Liverpool Hospital
ANZHPBA Fellow, Alfred Health Sydney, New South Wales, Australia
G. Bruce Mann
Nigel B. Jamieson MBBS, PhD, FRACS
MBChB, BSc(Hons), FRCS, PhD Professor of Surgery, University of Melbourne
Lecturer in Surgery and Cancer Research UK Clinician Director of Breast Tumour Stream, Victorian
Scientist, University of Glasgow Comprehensive Cancer Centre
Honorary Consultant in HPB Surgery, Glasgow Royal Melbourne, Victoria, Australia
Infirmary
Glasgow, UK Vijayaragavan Muralidharan
BMedSci, MBBS (Hons), MSurgEd, PhD, FRACS
Yazmin Johari Associate Professor of Surgery, University of Melbourne
MBBS(Hons) Hepatopancreatobiliary Surgeon, Austin Health
General Surgery Registrar, Alfred Health Melbourne, Victoria, Australia
Sonal Nagra
Ian T. Jones MBBS, MMed(Surg), FRACS
MBBS, FRCS, FRACS, FASCRS Senior Lecturer in Rural General Surgery
Clinical Professor of Surgery, University of Melbourne Deakin University
Colorectal Surgeon, Royal Melbourne Hospital Consultant Surgeon, University Hospital Geelong
Melbourne, Victoria, Australia Geelong, Victoria, Australia
Rodney T. Judson Mehrdad Nikfarjam

MBBS, FRACS, FRCS MD, PhD, FRACS
Associate Professor of Surgery, University of Melbourne Associate Professor of Surgery, University of Melbourne
Head of Trauma Service, Royal Melbourne Hospital Hepatopancreatobiliary Surgeon, Austin Health
Contributors xi
Stephen O’Leary Jeffrey V. Rosenfeld AC, OBE

MBBS, BMedSci, PhD, FRACS MBBS, MS, MD, FRACS, FRCS(Ed), FACS, IFAANS,
Professor of Otolaryngology, University of Melbourne FRCS (Glasg, Hon), FCNST(Hon), FRCST(Hon),
Ear, Nose and Throat Surgeon, Royal Victorian Eye and FACTM, MRACMA
Ear Hospital Director, Monash Institute of Medical Engineering
Melbourne, Victoria, Australia Senior Neurosurgeon, Alfred Health
Geraldine J. Ooi
MBBS, BMedSci (Hons) Peter S. Russell
Senior Registrar, Centre for Obesity Research and BSc, PGDipSci, MBChB
Education (CORE), Monash University Research Fellow, Department of Surgery, University of
Senior Registrar in General Surgery, Alfred Health Auckland
Melbourne, Victoria, Australia Auckland, New Zealand
Kurvi Patwala Hani Saeed

MBBS(Hons) MD, BPharm
General Medical Registrar, Austin Health Vascular Surgery Registrar, Eastern Health
Marcos V. Perini Gurfateh Singh Sandhu

MD, PhD, FRACS BSc (Advanced), MBBS
Senior Lecturer in Surgery, University of Melbourne Vascular Surgery Registrar, Royal Prince Alfred Hospital
Hepatopancreaticobiliary and Liver Transplant Surgeon, Sydney, New South Wales, Australia
Austin Health
Melbourne, Victoria, Australia Alan C. Saunder
MBBS, FRACS
William R.G. Perry Senior Lecturer in Surgery, Monash University
BSc, MBChB, MPH, FRACS Vascular and Transplant Surgeon and Medical
Senior Clinical Fellow, Department of Colorectal Surgery, Director, Surgery and Interventional Services Program,
Oxford University Hospitals NHS Foundation Trust Monash Health
Oxford, UK Melbourne, Victoria, Australia
Jeffrey J. Presneill Shomik Sengupta

MBBS(Hons), PhD, MBiostat, PGDipEcho, FRACP, FCICM
MBBS, MS, MD, FRACS
Associate Professor in Medicine
Professor of Surgery, Monash University
University of Melbourne
Urologist, Eastern Health
Deputy Director, Intensive Care Unit
Royal Melbourne Hospital
Jonathan Serpell
MBBS, MD, MEd, FRACS, FACS, FRCSEd (ad hom)
Raffi Qasabian
Professor of Surgery, Monash University
BSc(Hons), MBBS(Hons), FRACS
Director of General Surgery and Head, Breast, Endocrine
Vascular and Endovascular Surgeon, Royal Prince Alfred
and General Surgery Unit, Alfred Health
Hospital
Sydney, New South Wales, Australia
Kenny Rao Rose Shakerian

MBBS, MS MBBS, DMedSci, FRACS
Urology Registrar, Eastern Health General Surgeon, Royal Melbourne Hospital
Fairleigh Reeves Susan Shedda

MBBS (Hons), DipSurgAnat MBBS, MPH, FRACS
Urology Registrar, Royal Melbourne Hospital Colorectal Surgeon, Royal Melbourne Hospital and
Melbourne, Victoria, Australia Royal Women’s Hospital
Arthur J. Richardson
MBBS, DClinSurg, FRACS, FACS Julian A. Smith
Associate Professor of Surgery, University of Sydney MBBS, MS, MSurgEd, FRACS, FACS, FFSTRCSEd,
Head, Hepatopancreatobiliary Surgery, Westmead FCSANZ, FAICD
Hospital Head, Department of Surgery (School of Clinical
Sydney, New South Wales, Australia Sciences at Monash Health), Monash University
xii Contributors
Head, Department of Cardiothoracic Surgery, Ioana Tichil

Monash Health MD
Melbourne, Victoria, Australia Burns Fellow, Victorian Adult Burns Service, Alfred Health
John Spillane
MBBS, FRACS Joe J. Tjandra (deceased)
Lecturer in Surgery, University of Melbourne MBBS, MD, FRACS, FRCS(Eng), FRCPS, FASCRS
Surgical Oncologist, Division of Cancer Surgery, Peter Formerly Associate Professor of Surgery, University of
MacCallum Cancer Centre Melbourne
Melbourne, Victoria, Australia Colorectal Surgeon and Surgical Oncologist, Royal
Melbourne Hospital
David Story Melbourne, Victoria, Australia
MBBS (Hons), MD, BMedSci (Hons), FANZCA
Chair of Anaesthesia, Centre for Integrated Critical Care, Val Usatoff
University of Melbourne MBBS(Hons), MHSM, FRACS, FCHSM
Melbourne, Victoria, Australia Associate Professor of Surgery, University of Melbourne
Head, Upper Gastrointestinal and
Hepatopancreatobiliary Surgery, Western Health
James Tatoulis AM
MBBS, MS, MD, FRACS, FCSANZ
Professor of Cardiothoracic Surgery, University of
Melbourne
Neil Vallance
MBBS, FRACS
Director of Cardiothoracic Surgery, Royal Melbourne
Hospital
Emeritus Head, Department of Otolaryngology, Head
and Neck Surgery, Monash Health
Jin W. Tee
BMSc, MBBS, MD, FRACS David A.K. Watters AM, OBE
Associate Professor of Surgery, Monash University BSc (Hons), ChM, FRCSEd, FRACS
Complex Spine and Neurosurgeon, Spine Oncology Professor of Surgery, Deakin University
Surgery, Alfred Health Alfred Deakin Professor of Surgery
Head, Spine and Neurotrauma, National Trauma Deakin University and Barwon Health
Research Institute General and Endocrine Surgeon
Melbourne, Victoria, Australia University Hospital Geelong
Geelong, Victoria, Australia
Robert J.S. Thomas OAM
MBBS, MS, FRACS, FRCS(Eng) John A. Windsor
Professorial Fellow and Special Advisor on Health, BSc, MBChB, MD, FRACS, FACS
University of Melbourne Professor of Surgery, University of Auckland
Melbourne, Victoria, Australia General, Pancreatobiliary, Gastro‐oesophageal and
Laparoscopic Surgeon, Auckland City Hospital
Benjamin N.J. Thomson Auckland, New Zealand
MBBS, DMedSci, FRACS, FACS
Clinical Associate Professor in Surgery, University of Homayoun Zargar
Melbourne MBChB, FRACS
Head, Department of General Surgical Specialties Senior Lecturer in Surgery, University of Melbourne
Royal Melbourne Hospital Urologist, Royal Melbourne Hospital
Preface
Medical students and trainees must possess an grounding for students in surgical diseases, problems
understanding of basic surgical principles, a knowl- and management. Apart from forming the core cur-
edge of specific surgical conditions, be able to per- riculum for medical students, surgical trainees will
form a few basic procedures and be part of a also find the Textbook of Surgery beneficial in their
multidisciplinary team that manages the patient in studies and their practice.
totality. All students of surgery must also be aware The fourth edition of the Textbook of Surgery
of the rapid developments in basic sciences and includes new or extensively revised chapters on the
technology and understand where these develop- assessment of surgical risk, the management of sur-
ments impinge on surgical practice. gical wounds, introduction to the operating theatre,
The Textbook of Surgery is intended to supply emergency general surgery, obesity and bariatric
this information, which is especially relevant given surgery, lower gastrointestinal surgery, endovascu-
the current content of the surgical curriculum for lar therapies, benign urological conditions, genitou-
undergraduates. Each topic is written by an expert rinary oncology, sudden‐onset severe headache and
in the field from his or her own wisdom and experi- the red eye.
ence. All contributors have been carefully chosen With ever‐expanding medical knowledge, a core
from the Australasian region for their authoritative amount of instructive and up‐to‐date information
expertise and personal involvement in undergradu- is presented in a concise fashion. Important leading
ate teaching and postgraduate training. references of classic publications or up‐to‐date
In this textbook we have approached surgery literature have been provided for further reading. It
from a practical viewpoint while emphasising the is our aim that this textbook will stimulate students
relevance of basic surgical principles. We have to refer to appropriate reviews and publications for
attempted to cover most aspects of general surgery additional details on specific subjects.
including its subspecialties and selected topics of We have presented the textbook in an attractive
other surgical specialties, including cardiothoracic and easily readable format by extensive use of
surgery, neurosurgery, plastic surgery, ophthalmol- tables, boxes and illustrations. We hope that this
ogy, orthopaedic surgery, otolaryngology/head and fourth edition will continue to be valuable to
neck surgery, urology and vascular surgery. undergraduate, graduate and postgraduate stu-
Principles that underlie the assessment, care and dents of surgery, and for general practitioners and
treatment of surgical patients are outlined, followed physicians as a useful summary of contemporary
by sections on various surgical disorders. The final surgery.
section presents a practical problem‐solving approach
to the diagnosis and management of common surgi- Julian A. Smith
cal conditions. In clinical practice, patients present Andrew H. Kaye
with symptoms and signs to the surgeon who then Christopher Christophi
has to formulate care plans, using such a problem‐ Wendy A. Brown
solving approach. This textbook provides a good Melbourne, Australia
xiii
Acknowledgements
This book owes its existence to the contributions of we owe a debt of gratitude to our loving families,
our talented surgeons and physicians from through- specifically our spouses and partners – Sally Smith,
out Australia, New Zealand and Asia. We are Judy Kaye, Helena Fisher and Andrew Cook – as it
indebted to the staff of Wiley in Australia (Simon was precious time spent away from them which
Goudie) and in Oxford (Claire Bonnett, Jennifer allowed completion of this textbook.
Seward, Deirdre Barry and Nick Morgan) for their The editors wish to dedicate this edition to two
support and diligence. We thank Associate Professor highly esteemed previous editors, the late Joe
David Francis, Mr Alan Cuthbertson and Professor J. Tjandra and the late Gordon J.A. Clunie. Both
Robert Thomas for their assistance with previous were inspirational surgical educators who left an
editions, which laid the foundation for this fourth enduring legacy amongst the many students, train-
edition. ees and colleagues with whom they interacted over
Our patients, students, trainees and surgical men- many years.
tors have all been an inspiration to us, but above all
xiv
Section 1
Principles of Surgery
1 Preoperative management
Julian A. Smith
Department of Surgery (School of Clinical Sciences at Monash Health), Monash University
and Department of Cardiothoracic Surgery, Monash Health, Clayton, Victoria, Australia
act of placing a signature on a form. That signature

Introduction in itself is only meaningful if the patient has been
through a reasonable process that has left them in a
This chapter covers care of the patient from the
position to make an informed decision.
time the patient is considered for surgery through
There has been much written around issues of
to immediately prior to operation and deals with
informed consent, and the medico‐legal climate has
important generic issues relating to the care of all
changed substantially in the past decade. It is
surgical patients. Whilst individual procedures each
important for any doctor to have an understanding
have unique aspects to them, a sound working
of what is currently understood by informed con-
understanding of the common issues involved in
sent. Although the legal systems in individual juris-
preoperative care is critical to good patient out-
dictions may differ with respect to medical
comes. The important elements of preoperative
negligence, the standards around what constitutes
management are as follows.
informed consent are very similar.
• History taking: the present surgical condition
Until relatively recently, the standard applied to
and a general medical review.
deciding whether the patient was given adequate and
• Physical examination: the present surgical condi-
appropriate information with which to make a deci-
tion and a general examination.
sion was the so‐called Bolam test – practitioners are
• Reviewing available diagnostic investigations.
not negligent if they act in accordance with practice
• Ordering further diagnostic and screening
accepted by a reasonable body of medical opinion.
investigations.
Recent case law from both Australia and overseas
• Investigating and managing known or discovered
has seen a move away from that position. Although
medical conditions.
this area is complex, the general opinion is that a doc-
• Obtaining informed consent.
tor has a duty to disclose to a patient any material
• Scheduling the operation and any special prepa-
risks. A risk is said to be material if ‘in the circum-
rations (e.g. equipment required).
stances of that particular case, a reasonable person in
• Requesting an anaesthetic review.
the patient’s position, if warned of the risk would be
• Marking the operative site/side.
likely to attach significance to it or the medical prac-
• Prescribing any ongoing medications and proph-
titioner is, or should reasonably be aware that the
ylaxis against surgical site infection and deep
particular patient, if warned of the risk would attach
venous thrombosis.
significance to it’. It is important that this standard
• Planning postoperative recovery and possibly
relates to what a person in the patient’s position
rehabilitation.
would do and not just any reasonable person.
Important factors when considering the kinds
of information to disclose to patients include the
Informed consent following.
• The nature of the potential risks: more common
Although often thought of in a purely medico‐legal and more serious risks require disclosure.
way, the process of ensuring that a patient is • The nature of the proposed procedure: complex
informed about the procedure they are about to interventions require more information as do
undergo is a fundamental part of good‐quality procedures when the patient has no symptoms or
patient care. Informed consent is far more than the illness.
Textbook of Surgery, Fourth Edition. Edited by Julian A. Smith, Andrew H. Kaye, Christopher Christophi and Wendy A. Brown.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
3
4 Principles of Surgery
• The patient’s desire for information: patients ◦◦ ensure care is provided in an appropriate
who ask questions make known their desire for environment.
information and they should be told. • To identify important social issues which may
• The temperament and health of the patient: anx- have a bearing on the planned procedure and the
ious patients and patients with health problems or recovery period.
other relevant circumstances that make a risk more • To familiarise the patient with the planned proce-
important for them may need more information. dure and the hospital processes.
• The general surrounding circumstances: the Clearly the preoperative evaluation should include
information required for elective procedures a careful history and physical examination, together
might be different from that required in those with structured questions related to the planned
conducted emergently. procedure. Simple questions related to exercise
Verbal discussions concerning the therapeutic tolerance (such as ‘Can you climb a flight of stairs
options, potential benefits and risks along with without being short of breath?’) will often yield as
common complications are often supplemented much useful information as complex tests of cardi-
with procedure‐specific patient explanatory bro- orespiratory reserve. The clinical evaluation will
chures. These provide a straightforward illustrated be coupled with a number of blood and radio-
account for the patient and their relatives to con- logical tests. There is considerable debate as to the
sider and may be a source of clarification and/or value of many of the routine tests performed, and
further questions about the proposed operation. each hospital will have its own protocol for such
What does this mean for a medical practitioner? evaluations.
Firstly, you must have an understanding of the legal Common patient observations, investigations
framework and standards. Secondly, you must docu- and screening tests prior to surgery include:
ment how appropriate information was given to • vital signs (blood pressure, pulse rate, respiratory
patients – always write it down. If discussion points rate, temperature) and pulse oximetry
are not documented, it may be argued that they • body weight
never occurred. On this point, whilst explanatory • urinalysis
brochures can be a very useful addition to the p rocess • full blood examination and platelet count
of informed consent they do not remove the need to • urea and electrolytes, blood sugar, tests of liver
undertake open conversations with the patient. function
Doctors often see the process of obtaining • blood grouping and screen for irregular antibod-
informed consent as difficult and complex, and this ies (‘group and hold’)
view is leant support by changing standards. • tests of coagulation, i.e. international normalised
However, the principles are relatively clear and not ratio (INR) and activated partial thromboplastin
only benefit patients but their doctors as well. A fully time (APTT)
informed patient is much more likely to adapt to the • chest X‐ray
demands of a surgical intervention, and should a • electrocardiogram (ECG).
complication occur, they and their relatives almost On the basis of the outcomes of this preoperative
invariably accept such misfortune far more readily. evaluation a number of risk stratification systems
have been proposed. One in widespread daily use is
the relatively simple ASA (American Society of
Preoperative assessment Anesthesiologists) system (see Chapter 3, Table 3.3).
The preoperative assessment and work‐up will
The appropriate assessment of patients prior to sur- be guided by a combination of the nature of the
gery to identify coexisting medical problems and to operation proposed and the overall ‘fitness’ of the
plan perioperative care is of increasing importance. patient. Whilst there are a number of ways of look-
Modern trends towards the increasing use of day‐ ing at the type of surgery proposed, a simple three‐
of‐surgery admission even for major procedures way classification has much to commend it.
have increased the need for careful and systematic • Low risk: poses minimal physiological stress and
preoperative assessment, much of which occurs in a risk to the patient, and rarely requires blood
pre‐admission clinic (PAC). transfusion, invasive monitoring or intensive
The goals of preoperative assessment are: care. Examples of such procedures would be
• To identify important medical issues in order to groin hernia repair, cataract surgery and
◦◦ optimise their treatment arthroscopy.
◦◦ inform the patient of additional risks associ- • Medium risk: moderate physiological stress
ated with surgery (fluid shifts, cardiorespiratory effects) and risk.
1: Preoperative management 5
Usually associated with minimal blood loss. Evaluation of the elderly

Potential for significant problems must be appre- asymptomatic patient
ciated. Examples would be laparoscopic chole-
Ageing increases the likelihood of asymptomatic
cystectomy, hysterectomy and hip replacement.
conditions and screening investigations are therefore
• High risk: significant perioperative physiological
more stringently applied to older, apparently healthy
stress. Often requires blood transfusion or infu-
patients. Elderly patients (aged over 70 years) have
sion of large fluid volumes. Requires invasive
increased mortality and complication rates for surgi-
monitoring and will often need intensive care.
cal procedures compared with young patients.
Examples would be aortic surgery, major gastro-
Problems are related to reduced functional reserve,
intestinal resections and thoracic surgery.
coexisting cardiac and pulmonary disease, renal
A low‐risk patient (ASA I or II) will clearly require
impairment, poor tolerance of blood loss and greater
a far less intensive work‐up than a high‐risk patient
sensitivity to analgesics, sedatives and anaesthetic
(ASA III or IV) undergoing a high‐risk operation.
agents.
Areas of specific relevance to perioperative care
Complications of atelectasis, myocardial infarc-
are cardiac disease and respiratory disease. It is
tion, arrhythmias and heart failure, pulmonary
important that pre‐existing cardiorespiratory dis-
emboli, infection and nutritional and metabolic
ease is optimised prior to surgery to minimise the
disorders are all more frequent. Separation of the
risk of complications. Patients with cardiac disease
effects of ageing, frailty and of associated diseases
can be stratified using a number of systems (New
is difficult. Most of the increased mortality and
York Heart Association Functional Class for angina
morbidity is due to associated disease.
or heart failure; Goldman or Detsky indices) and
Special attention needs to be paid to the assess-
this stratification can be used to guide work‐up and
ment of cardiac, respiratory, renal and hepatic func-
interventions and provide a guide to prognosis.
tion along with patient frailty before operation in
One of the most important respiratory factors is
elderly patients.
whether the patient is a smoker. There is now clear
evidence that stopping smoking for at least 4 weeks
prior to surgery significantly reduces the risk of res-
piratory specific or generic complications. Patient safety (see also Chapter 12)
Once in hospital, and particularly once under

Evaluation of the healthy patient
anaesthetic, patients rely upon the systems and
Patients with no clinically detectable systemic illnesses policies of individuals and healthcare institutions
except their surgical problem are classified into to minimise the risk of inadvertent harm. Whilst
ASA class I. Mortality for low‐risk surgical proce- every hospital will have slightly different policies
dures in this group is very low and complications the fundamental goals of these include the
are likely to be due to technical errors. The mortality following.
for major high‐risk surgical procedures in such • The correct patient gets the correct operation on
patients is also low, of the order of a few per cent. the correct side or part of their body. An appro-
All such patients require detailed systems review priate method of patient identification and
by history and physical examination prior to the patient marking must be in place. It must be clear
operation. Preoperative special tests may be added in to all involved in the procedure, particularly for
order to detect any subclinical disease that may operations on paired limbs or organs when the
adversely affect surgery and to provide baseline val- incorrect side could be operated upon.
ues for comparison in the event of postoperative • The patient is protected from harm whilst under
complications. These tests should be sufficiently sen- anaesthetic. When under a general anaesthetic
sitive to detect an abnormality, yet specific enough to the patient is vulnerable to a number of risks.
avoid the chances of over‐diagnosis. The prevalence Important amongst these are pressure effects on
of the disease or condition being looked for is likely nerves, for example those on the common pero-
to be low in a healthy asymptomatic patient popula- neal nerve as it winds around the head of the
tion. Thus, most tests are likely to be within the nor- fibula.
mal range. Inappropriate and excessive tests increase • Previous medical problems and allergies are iden-
the likelihood of a false‐positive result due to chance. tified and acted upon.
With extensive multiphasic screening profiles of • Protocols for the prevention of perioperative
healthy individuals, about 5% of healthy normal infection and venous thromboembolism are
people will show one abnormal result. followed.
can, when used appropriately, significantly reduce

Prophylaxis infectious complications, inappropriate or pro-
longed use can leave the patient susceptible to
Infection infection with antibiotic‐resistant organisms such
Infections remain a major issue for all surgical as MRSA or VRE.
procedures and the team caring for the patient
Factors related to both the patient and the
needs to be aware of relevant risks and act to planned procedure govern the appropriate use of
minimise such risks. antibiotics in the prophylactic setting.
Before discussing the use of prophylactic antibiot-
ics for the prevention of perioperative infection, it is Patient‐related factors
very important that issues of basic hygiene are dis-
Patients with immunosuppression and pre‐existing
cussed (see also Chapters 9 and 12). Simple measures
implants and patients at risk for developing infec-
adopted by all those involved in patient care can
tive endocarditis must receive appropriate prophy-
make a real difference to reducing the risk of hospi-
laxis even when the procedure itself would not
tal‐acquired infection. The very widespread and sig-
indicate their use.
nificant problems with antibiotic‐resistant organisms
such as meticillin‐resistant Staphylococcus aureus
Procedure‐related factors
(MRSA) and vancomycin‐resistant Enterococcus
faecalis (VRE) have reinforced the need for such Table 1.1 indicates the risk of postoperative surgi-
basic measures. cal site infections with and without the use of pro-
• Wash your hands in between seeing each and phylactic antibiotics. In addition to considering
every patient. the absolute risk of infection, the potential conse-
• Wear gloves for removing/changing dressings. quences of infection must also be considered; for
• Ensure that the hospital environment is as clean example, a patient undergoing a vascular graft (a
as possible. clean procedure) must receive appropriate antibi-
These measures, especially hand hygiene, should be otic cover because of the catastrophic consequences
embedded into the psyche of all those involved in of graft infection.
patient care.
In addition to the very important matters of
Venous thromboembolism
hygiene and appropriate sterile practice, antibiotics
should be used in certain circumstances to reduce Deep vein thrombosis (DVT) is a not uncommon
the risk of perioperative surgical site infection. Each and potentially catastrophic complication of sur-
hospital will have individual policies on which par- gery. The risk for developing DVT ranges from a
ticular antibiotics to use in the prophylactic setting fraction of 1% to 30% or greater depending on
(see also Chapters 9 and 12). The antibiotics are both patient‐ and procedure‐related factors. Both
usually administered at or shortly before the induc- patient‐ and procedure‐related factors can be
tion of anaesthesia and continued for no more than classified as low, medium or high risk (Table 1.2).
24 hours postoperatively. It is also important to High‐risk patients undergoing high‐risk operations
state that whilst the use of prophylactic antibiotics will have a risk for DVT of up to 80% and a
Table 1.1 Risks of postoperative surgical site infection.
Wound infection rate (%)
Without prophylactic With prophylactic

Type of procedure Definition antibiotics antibiotics
Clean No contamination; gastrointestinal, 1–5 0–1

genitourinary or respiratory tracts not
breached
Clean‐contaminated Gastrointestinal or respiratory tract 10 1–2
opened but without spillage
Contaminated Acute inflammation, infected urine, bile, 20–30 10
gross spillage from gastrointestinal tract
Dirty Established infection 40–50 10
Table 1.2 Prevention of deep vein thrombosis.
Operative risk factors
Low (e.g. hernia Medium (e.g. general High (e.g. pelvic cancer,
repair) abdominal surgery) orthopaedic surgery)
Patient risk Low (age <40, no No prophylaxis Heparin Heparin and mechanical
factors risk factors) devices
Medium (age >40, Heparin Heparin Heparin and mechanical
one risk factor) devices
High (age >40, Heparin and Heparin and Higher‐dose heparin,
multiple risk factors) mechanical devices mechanical devices mechanical devices
pulmonary embolism risk of 1–5% when prophy- in‐depth preoperative preparation. Whilst the prin-
laxis is not used. These risks can be reduced by at ciples already outlined are still valid, a number of
least one order of magnitude with appropriate additional issues are raised.
interventions.
Whilst a wide variety of agents have been trialled Informed consent
for the prevention of DVT, there are currently only
Whilst there is still a clear need to ensure that patients
three widely used methods.
are appropriately informed, there are fewer opportu-
• Graduated compression stockings: these stock-
nities to discuss the options and potential complica-
ings, which must be properly fitted, reduce
tions with the patient and their family. In addition,
venous pooling in the lower limbs and prevent
the disease process may have resulted in the patient
venous stagnation.
being confused. The team caring for the patient needs
• Mechanical calf compression devices: these work
to judge carefully the level of information required in
by intermittent pneumatic calf compression and
this situation. Although it is very important that fam-
thereby encourage venous return and reduce
ily members are kept informed, it has to be remem-
venous pooling.
bered that the team’s primary duty is towards the
• Heparin: this drug can be used in its conventional
patient. This sometimes puts the team in a difficult
unfractionated form or as one of the fractionated
position when the views of the patient’s family differ
low‐molecular‐weight derivatives. The fraction-
from those which the team caring for the patient
ated low‐molecular‐weight heparins offer the
hold. If such an occasion arises then careful discus-
convenience of once‐ or twice‐daily dosing for
sion and documentation of the decision‐making pro-
the majority of patients. It must however be
cess is vital. Increasingly, patients of very advanced
remembered that the anticoagulant effect of the
years are admitted acutely with a surgical problem in
low‐molecular‐weight heparins may not easily
the setting of significant additional medical prob-
be reversed, and where such reversal may be
lems. It is with this group of patients that specific
important, standard unfractionated heparin
ethical issues around consent and appropriateness of
should be used.
surgery occur. It is important that as full as possible a
The three methods are complementary and are
picture of the patient’s overall health and quality of
often used in combination, depending on the patient
life is obtained and that a full and frank discussion of
and operative risk factors (Table 1.2).
the options, risks and benefits takes place.
The systematic use of such measures is very
important if optimal benefit is to be gained by the
Preoperative resuscitation
potential reduction in DVT.
It is important that wherever possible significant
fluid deficits and electrolyte abnormalities are cor-
Preoperative care of the acute surgical rected prior to surgery. There is often a balance to
patient be made between timely operative intervention and
the degree of fluid resuscitation required. An early
A significant number of patients will present with discussion between surgeon, anaesthetist and, when
acute conditions requiring urgent or emergency required, intensivist can help plan the timing of sur-
surgical operations. There may be little time for an gical intervention.
Pre‐existing medical comorbidities Diabetes mellitus

There is clearly less time to address these issues and Diabetes mellitus is one of the most frequently seen
it may not be possible to address significant ongo- medical comorbidities that complicate periopera-
ing medical problems. Clearly such comorbidities tive care. It is clearly important that patients with
should be identified, and all involved with planning diabetes mellitus are appropriately worked up for
the operation should be informed. The issues are surgery.
most acute for significant cardiac, respiratory, In the weeks leading up to elective surgery the
hepatic or renal disease. management of the diabetes should be reviewed
and blood glucose control optimised. Particular
attention should be paid to HbA1c levels as an
Preoperative nutrition
index of diabetic control as well as cardiovascular
and renal comorbidities during the preoperative
An awareness of the nutritional status of patients is
assessment.
important and such awareness should guide the
Generally, patients with diabetes should be
decisions about nutritional support (see Chapter 7).
scheduled for surgery first case in the morning.
The well‐nourished adult patient should be fasted
Diet‐controlled patients require no special preop-
for at least 6 hours prior to anaesthesia to minimise
erative preparation. For patients taking oral hypo-
the risk of aspiration. Where possible regular medi-
glycaemic drugs, the drugs should be stopped the
cations, especially those for cardiovascular and res-
night before surgery and the blood glucose moni-
piratory conditions, should be continued.
tored. Patients with insulin‐dependent diabetes
Before an operation the malnourished patient
should receive a reduced dose of insulin and/or a
should, whenever possible, be given appropriate
shorter‐acting insulin or be commenced on an
nutritional support. There is no doubt that signifi-
intravenous insulin infusion. There are two
cant preoperative malnutrition increases the risk of
approaches to this.
postoperative complications (>10–15% weight
• Variable‐rate insulin infusion: the patient’s blood
loss). If possible, such nutrition should be given
glucose levels are monitored regularly and the
enterally, reserving parenteral nutrition for the
rate of insulin infusion adjusted. An infusion of
minority of patients in whom the gastrointestinal
dextrose is continued throughout the period of
tract is not an option. Parenteral nutrition is associ-
insulin infusion.
ated with increased costs and complications and is
• Single infusion of glucose, insulin and potassium
of proven benefit only in the seriously malnour-
(GIK): whilst this method has the advantage of
ished patient, when it should be given for at least
simplicity, it is not possible to adjust the rates of
10 days prior to surgery for any benefits to be seen.
glucose and insulin infusion separately and the
There is increasing evidence that enteral feeds spe-
technique can lead to the administration of exces-
cifically formulated to boost certain immune
sive amounts of free water.
parameters offer clinical benefits for patients about
The variable‐rate infusion is the most widespread
to undergo major surgery.
approach and although more involved in terms of
After operation any patient who is unable to take
monitoring offers better glycaemic control. This in
in normal diet for 7 days or more should receive
itself is associated with better patient outcomes.
nutritional support, which as before operation
should use the enteral route whenever possible.
Cardiac disease
Surgical risk is increased in the presence of cardiac
Specific preoperative issues
disease. Consideration must be given to balancing
the risk to the patient if the procedure is abandoned
Allergies
or delayed with the additional risk caused by the
A history of adverse or allergic reactions to medica- presence of cardiac disease. Emergency operations
tions or other substances must be documented and for life‐threatening conditions should proceed
repeat administration and/or exposure avoided as a regardless but elective surgery should be deferred in
life‐threatening anaphylaxis may result. Examples the presence of recent‐onset angina, unstable
of allergens within surgical practice include antibi- angina, recent myocardial infarction, severe aortic
otics, skin preparations (e.g. iodine), wound dress- valve stenosis, high‐degree atrioventricular block,
ing adhesives and latex. A complete latex‐free severe hypertension and untreated congestive car-
environment is required for those patients with a diac failure. Time should be spent investigating the
known latex allergy. condition and optimising therapy, frequently with
cardiological assistance. The introduction of beta‐ deferred in the presence of an active respiratory
blocker therapy to slow heart rate and occasionally infection or an acute exacerbation of asthma or
myocardial revascularisation (by percutaneous COPD.
coronary intervention or coronary artery bypass
Additional respiratory preparation may include
grafting) may be required in advance of surgery on chest physiotherapy, postural drainage, antibiotics
another system. for an acute infection with a positive sputum cul-
ture and inhaled bronchodilators or corticosteroid
Anticoagulant or antiplatelet therapy therapy. A formal preoperative pulmonary rehabili-
tation program may be indicated. Regional anaes-
Patients on warfarin should be transferred to hepa-
thesia is frequently preferred in patients with severe
rin or enoxaparin well in advance of surgery to
respiratory dysfunction.
ensure that the warfarin effect has worn off.
Heparin can be ceased for a short time in the perio-
perative period: withhold an infusion 4 hours Long‐term corticosteroid therapy
before surgery and recommence once the risk of Long‐term corticosteroid therapy results in adrenal
postoperative bleeding is low. Subcutaneously suppression and an impaired response to surgical
administered heparin or enoxaparin is withheld the stress. High‐dose intravenous hydrocortisone
day or evening before surgery and recommenced administration (100 or 250 mg every 6 hours) will
later that day or the day after. Warfarin recom- be required during the perioperative period and
mences once the patient can take oral medication. when the patient is unable to take their regular
Rapid reversal of warfarin prior to an emergency medication or in the presence of postoperative com-
operation may be achieved with vitamin K, pooled plications especially infection.
fresh frozen plasma or clotting factors.
The new oral anticoagulants (dabigatran, apixa- Cerebrovascular disease
ban or rivaroxaban) are difficult to reverse acutely
and need to be ceased 2–5 days preoperatively. A Stroke may complicate major surgery especially in
specific dabigatran reversal agent has recently elderly patients with severe intracranial or extrac-
become available. A bridging regimen such as that ranial atherosclerotic disease faced with fluctua-
described above is also required. tions in blood pressure or cerebral blood flow. An
The antiplatelet agents (aspirin, clopidogrel or asymptomatic carotid bruit related to an internal
ticagrelor) taken alone or in combination should be carotid artery stenosis confirmed with Doppler
ceased at least 5 days prior to an operation. Bleeding ultrasonography may be the first indicator of such
will be highly problematic at the time of surgery disease. Patients with symptomatic carotid disease
especially if multiple antiplatelet agents are contin- (e.g. transient ischaemic attacks) should undergo
ued. Combined usage often follows coronary artery carotid endarterectomy prior to the planned sur-
stenting and so their withdrawal in the context of gery. However, there is no evidence that a prophy-
surgery should be discussed with the treating inter- lactic carotid endarterectomy is of benefit in the
ventional cardiologist. Elective surgery may need to asymptomatic patient.
be postponed if dual antiplatelet therapy cannot be
safely ceased. Chronic liver disease and obstructive
jaundice
Active smoking and respiratory disease
Chronic liver disease of any cause may predispose
All active smokers should be encouraged to cease the patient to surgical complications such as poor
for at least 4 weeks in advance of elective surgery in wound healing, sepsis, excessive bleeding, renal
order to lessen the risk of respiratory problems impairment and acute delirium. Each of the previ-
(atelectasis, acute pneumonia and respiratory fail- ously discussed screening investigations will be
ure) in the postoperative period. Patients unwilling required in addition to specific liver and biliary tree
or incapable of stopping smoking should be referred imaging and possibly liver biopsy. The decision to
to a dedicated support service to assist with such. operate on a patient with severe liver insufficiency
Patients with chronic obstructive pulmonary dis- must be carefully considered. Elective surgery
ease (COPD), asthma and obstructive sleep apnoea should be deferred whilst liver function is opti-
require a detailed respiratory assessment (including mised. Emergency surgery can often result in
peak flow, spirometry and arterial blood gas esti- acute liver decompensation especially in the
mation) especially if the patient reports significant presence of sepsis, haemorrhage, electrolyte distur-
exercise limitation. Elective surgery should be bances, hypoxia and hypoglycaemia.
Patients with obstructive jaundice (see through such physiological mechanisms as

Chapter 67) frequently have an abnormal coagula- increased cardiac output. The signs and symptoms
tion profile and require vitamin K, coagulation fac- of anaemia vary with its severity and are more
tors or pooled fresh frozen plasma to correct the marked if the anaemia has developed over a short
defect. Close attention needs to be paid to the period. Symptoms of weakness and tiredness,
patient’s fluid and electrolyte status in order to pre- breathlessness, palpitations and angina can occur
vent acute renal failure. The hepatic clearance of with moderate or severe anaemia. Pallor is the out-
some commonly administered medications may be standing physical sign. Pallor of the conjunctiva
impaired. and the palmar creases becomes apparent when the
haemoglobin level falls below 10 g/dL. Tachycardia
Chronic kidney disease and cardiac failure may accompany severe anae-
mia. Patients with significant or symptomatic anae-
All patients aged over 40 years should have their
mia should be evaluated by a specialist physician or
kidney function evaluated (urinalysis, serum creati-
haematologist, frequently in a dedicated anaemia
nine, estimated glomerular filtration rate and
clinic.
serum albumin) when major surgery is planned.
In the surgical patient, it is often possible to insti-
Documented chronic kidney disease does not man-
tute iron therapy prior to admission to hospital.
date deferral of elective surgery. Patients with
Anaemia is thus always best diagnosed and its
chronic kidney disease may experience an acute
cause determined during the first office consulta-
deterioration in kidney function if they become
tion in patients needing elective surgery. For iron
water or saline depleted. Acute kidney failure is the
deficiency anaemia caused by blood loss, oral iron
most significant complication of chronic kidney
therapy begins immediately so that anaemia can be
disease: prevention demands strict attention to
safely corrected prior to surgery. Patients with mod-
fluid and electrolyte balance (especially avoiding
erate iron deficiency or haemolytic anaemias do not
dehydration and maintaining a stable level of serum
pose an excessive risk provided the haemoglobin
potassium), maintaining kidney perfusion and
level and the blood volume are adequate (>10 g/dL)
accurate replacement of blood loss during surgery.
and cardiorespiratory function is normal.
Apart from acute kidney failure, the main compli-
In patients with megaloblastic anaemia surgery
cations of surgery in patients with chronic kidney
should be deferred, if possible, until specific therapy
disease are sepsis (including urinary tract infection),
such as vitamin B12 or folic acid has repaired the
poor wound healing and cardiovascular complica-
generalised tissue defect. In these cases, transfusion
tions (myocardial infarction and stroke).
alone may not render surgery safe, as protein metab-
olism of all cells is affected by the vitamin deficiency
Anaemia
that causes the macrocytic anaemia. Adequate tissue
As a general rule mild anaemia does not increase levels can be achieved with 1–2 weeks of oral treat-
the risk of surgery. However, if time permits the ment with vitamin B12 or folic acid or both.
cause of the anaemia should be identified before If it is not possible to correct the anaemia in a
elective surgery. Iron deficiency anaemia is best timely manner, the patient may be given concen-
detected early and treated by oral or intravenous trated red cells prior to surgery. A period of 3 days
iron. Patients with the anaemia of renal injury are should be allowed to elapse before operation as the
an exception to the general rule and can cope with transfused blood will not reach its maximum oxy-
quite low haemoglobin levels, due to an increase in gen‐carrying capacity until at least 2 days following
red cell 2,3‐diphosphoglycerate (2,3‐DPG) that transfusion. This period allows the transfused red
promotes better transfer of oxygen at the tissue cells to accumulate normal levels of 2,3‐DPG, nec-
level. However, in all patients the combination of essary for efficient delivery of oxygen to the tissues,
any degree of anaemia with decompensated cardio- and allows plasma dispersal restoring normovolae-
vascular disease (e.g. angina or obstructive airways mia. Elective surgery should seldom be undertaken
disease) warns that intensive perioperative care will when the haemoglobin concentration is less than
be necessary. 9–10 g/dL. Patients with long‐standing anaemia are
Preoperative haemoglobin measurement should able to tolerate a reduced level of haemoglobin bet-
be performed as a routine examination in all ter than those who have become acutely anaemic.
patients. Patients may have significant anaemia but This tolerance in chronic anaemia is a result of
no symptoms if the anaemia has developed slowly altered 2,3‐DPG concentration in the red cells, with
over a period of months and the body has compen- a favourable shift in the oxyhaemoglobin dissocia-
sated for the decreased oxygen‐carrying capacity tion curve to the right.
Woodhead K, Fudge L (eds) Manual of Perioperative Care:

Psychological preparation and mental an Eessential Guide. Oxford: Wiley Blackwell, 2012.
illness
All surgical patients must be in a relaxed state of MCQs

mind irrespective of the nature of the procedure
they are about to undergo. Anxiety and a fear Select the single correct answer to each question. The
of the unknown or of the potential complications correct answers can be found in the Answers section
of surgery are common, especially in the con- at the end of the book.
text of life‐threatening illnesses or procedures.
1 Without the use of prophylaxis the risk of deep calf
Reassurance can be achieved by empathetic sur-
vein thrombosis in a patient undergoing an anterior
geon communication with the patient and their
resection for rectal cancer is likely to be at least:
relatives and, in certain instances, by the provi-
a 10%
sion of specialised input from other healthcare
b 20%
professionals such as support nurses or
c 30%
psychologists.
d 50%
Patients with pre‐existing mental illness such as
anxiety, depression, psychoses, substance abuse or
2 Which of the following measures is most likely to
dementia who are preparing for an operation
reduce the risk of postoperative wound infection
require guidance from their treating healthcare pro-
with MRSA?
fessionals such that their condition is optimally
a 5 days of broad‐spectrum prophylactic antibiotics
managed in the perioperative period. The stress of
b ensuring the patient showers with chlorhexidine
surgery may worsen or unmask any pre‐existing
wash prior to surgery
mental condition. Care must be taken in the pre-
c a policy of staff hand washing between patients
scription of analgesics, anxiolytics, sedatives, anti-
d screening patients for MRSA carriage prior to
depressant and antipsychotic medications in these
surgery
patients.
3 Which of the following constitutes the legal standard

for the information that should be passed to a patient
Further reading to meet the requirements of ‘informed consent’?
a what a patient in that position would regard as
Smith JA, Yii MK. Pre-operative medical problems in sur-
reasonable
gical patients. In: Smith JA, Fox JG, Saunder AC, Yii
b what a reasoned body of medical opinion holds
MK (eds) Hunt and Marshall’s Clinical Problems in
Surgery, 3rd edn. Chatswood, NSW: Elsevier, as reasonable
2016:348–70. c a list of all possible complications contained
Wilson H. Pre-operative management. In: Falaschi P, within a patient explanatory brochure
Marsh DR (eds) Orthogeriatrics. Springer International d all serious complications that occur in more than
Publishing, 2017:63–79. 1% of patients
2 Assessment of surgical risk
Benjamin N.J. Thomson
University of Melbourne, Royal Melbourne Hospital Department of Surgery and Department of
General Surgery Specialties, Royal Melbourne Hospital, Melbourne, Victoria, Australia
For most surgical procedures the benefits of per-

Introduction forming surgery far outweigh the risks and the deci-
sion is easier, but for complex surgical procedures
This chapter reviews the assessment of risk for
the risks may outweigh any benefit. As outlined by
patients being considered for surgery or other inva-
the General Medical Council document the risks of
sive interventions.
not performing surgery also need to be considered.
Another important aspect is the likely outcome
from surgery. For example, most patients with ade-
Surgical risk
nocarcinoma of the head of the pancreas are not
suitable for surgical management due to the pres-
The definition of surgical risk is complex and dif-
ence of metastatic disease or involvement of the
fers depending on the point of view of the assessor.
major adjacent blood vessels. After appropriate
The risks of a particular surgical procedure may
preoperative staging only 5–10% of patients are
have a different value when considered by the sur-
suitable for surgery. Resection of the pancreatic
geon, anaesthetist, intensivist, patient or family
head (pancreaticoduodenectomy or Whipple’s pro-
member.
cedure) had a mortality of 50% in the 1950s,
What a surgeon may consider to be a small com-
whereas in 2018 the reported mortality in specialist
plication may be devastating to a patient depending
centres was 0.0–6.0%. Furthermore, operative
on their personal circumstances. For example, a
morbidity is close to 50%. Despite the high mor-
very rare risk of a unilateral recurrent laryngeal
bidity and mortality, the median survival for those
nerve injury leading to vocal cord palsy is well tol-
patients undergoing successful resection is only
erated by the majority of patients but is a disaster
14–24 months even in high‐volume centres. Clearly
for a professional singer. From a patient’s perspec-
any patient being considered for surgery needs also
tive surgical risk encompasses the mortality and
to understand the likelihood of successful treat-
morbidity relevant to their circumstances as well as
ment and to be able to balance this against their
the chance of successfully achieving the desired
own personal circumstances as well as the likeli-
outcome.
hood of morbidity and mortality.
The General Medical Council (GMC) of the UK
Another reason to assess surgical risk is identifica-
defines the risk of a proposed investigation or treat-
tion of high‐risk patients who may benefit from risk
ment using three criteria as well as the potential
reduction measures such as preoperative and intra-
outcome of taking no action (Box 2.1). This is an
operative optimisation as well as postoperative man-
integral component of the consent process required
agement in intensive care or high‐dependency units.
for each intervention or surgical procedure and
allows the patient and clinician to make a consen-
sual decision after considering the benefits of a pro-
cedure balanced against the associated risks. Assessment of surgical risk
However, there may be a number of treatment
options for each surgical pathology so the assess- There are three components to assessment of surgi-
ment of surgical risk also facilitates surgical cal risk. The first is the associated mortality and
decision‐making. morbidity of all surgical procedures. This can be
13
complications and other risks of surgery or inter-

Box 2.1 GMC‐UK definition of risk
ventions. It details the need for clear, accurate infor-
of investigation/treatment
mation about the risks of a proposed procedure
1 Side effects being presented in a way that the patient under-
2 Complications stands to enable them to make an informed
3 Failure of an intervention to achieve the desired decision. It is important to understand the patient’s
outcome views and preferences as well as the adverse out-
4 The potential outcome of taking no action comes that they are most concerned about. It is
Source: https://www.gmc‐uk.org/ethical‐guidance/ impossible to cover every possible side effect or
ethical‐guidance‐for‐doctors/consent/part‐2‐making‐ adverse outcome for each procedure but discussion
decisions‐about‐investigations‐and‐treatment#paragraph‐28 of the common adverse outcomes whether severe or
less serious is required as well as any possible
serious adverse outcomes.
obtained from multiple data sources that include There are a number of resources available to aid
personal audit, hospital audit, regional health data in the discussion, such as procedure‐specific infor-
or specialty group audits. Furthermore, there is mation pamphlets produced at a hospital level,
extensive published data available detailing the mor- surgical regulatory authorities or government

tality and morbidity of surgical procedures or inter- agencies.
ventions, although this is often reflective of leading
high‐volume centres. Therefore, publications that
report pooled data from all possible sources may Risk scoring systems
offer a clearer representation of surgical risks. A
brief overview of surgical risk is outlined in Table 2.1. Many tools have been developed to estimate both
The next two components of surgical risk assess- mortality and morbidity rates for individual
ment involve both subjective and objective parame- patients prior to a surgical procedure or interven-
ters. Subjective assessment includes information taken tion. Most are scoring systems that estimate risk for
from the history and examination of a patient as well all patients whilst others are specific for high‐risk
as recognition of patterns, clinical experience and patients or particular surgical procedures or disci-
intuition of the assessor. Often the experience of the plines. Like all tools they only provide an estimated
assessor in surgical practice may be pivotal in identify- risk and none are perfect. Most incorporate both
ing those patients at greater risk. Objective risk assess- physiological and comorbid data selected from
ment includes biochemical and haematological testing large databases of patients. These have then been
as well as assessment of physiological function, par- analysed with regression techniques to identify the
ticularly cardiac and respiratory function. Assessment key variables. Often a weighting is added to each of
of comorbidities also plays a role. There are also many the variables. Ideally these scoring systems should
risk prediction models and scoring systems available be validated in multiple other centres to analyse
that can be general or surgery specific. their usefulness for particular patient groups.
ASA
Discussing the risks of surgery
One of the first scoring systems developed was by
The General Medical Council of the UK has pub- the American Society of Anesthesiologists (ASA) in
lished guidance on the consent process and in par- 1963. It was a five‐point classification system for
ticular on the discussion of the side effects, assessment of a patient prior to surgery. It was
Table 2.1 Overview of the morbidity and mortality of common surgical procedures.
Surgical procedure Morbidity (%) Mortality (%)
Inguinal hernia repair 8–32 0–0.5

Appendicectomy 3.0–28.7 0.9–2.8
Laparoscopic cholecystectomy 14.7–21.4 0.3
Pancreaticoduodenectomy 20–54 0–6.0
Oesophagectomy 25–45 0.7–10.0
Coronary artery bypass grafting 30 1.5–2.5
2: Assessment of surgical risk 15
Table 2.2 American Society of Anesthesiologists expansion and improvement in the prognostic esti-
classification of mortality rates. mates led to the development of APACHE III.
APACHE was never designed to predict mortal-
ASA rating Number Deaths (%) ity in individual patients. Furthermore, the ability
1 92 227 0.001 to predict an individual’s probability of survival
2 367 161 0.002 depends upon response to therapy over time. The
3 195 829 0.028 APACHE system is predominantly a guide for
4 45 118 0.304 intensive care patients and therefore assessment of
5 353 6.232 critically ill patients rather than a guide for elective
1E 3 018 0.000 surgery.
2E 12 188 0.033
3E 7 109 0.155
4E 5 000 3.280 POSSUM
5E 899 19.911
The Physiological and Operative Severity Score for
the enumeration of Mortality and morbidity
Source: Hopkins TJ, Raghunathan K, Barbeito A et al.
Associations between ASA physical status and
(POSSUM) was first described in 1991. Rather than
postoperative mortality at 48 h: a contemporary a system for intensive care patients it was designed
dataset analysis compared to a historical cohort. as a scoring system to estimate morbidity and mor-
Perioper Med 2016;5:29. tality following surgery. It provides a risk‐adjusted
prediction of outcome. It is the most widely used
surgical risk scoring system in the UK. Various
subsequently revised with a sixth category coding modifications have been described and validated
for emergency patients. It is a combination of sub- for colorectal, oesophagogastric and vascular
jective anaesthetic opinion with an objective assess- patient groups. The Portsmouth P‐POSSUM was
ment of the patient’s fitness for surgery. The developed in 1998 and is now the most commonly
majority of hospitals and anaesthetists in Australia used in the UK.
use it routinely.
The ASA classification is as follows.
• ASA I: a normal healthy patient.
Pre‐admission clinics
• ASA II: a patient with mild systemic disease.
• ASA III: a patient with severe systemic disease.
Pre‐admission clinics have been established for
• ASA IV: a patient with severe systemic disease
more than 20 years. They have many different roles
that is a constant threat to life.
that include administration, surgical clerking, con-
• ASA V: a moribund patient who is not expected
sent, preoperative education as well as anaesthetic
to survive without the operation.
review. They provide an excellent environment for
• ASA VI: a declared brain‐dead patient whose
assessing surgical risk as well as for optimising
organs are being removed for donor purposes.
patients’ medical conditions prior to surgery. There
The coding for emergency patients is marked
are very few studies assessing the efficacy of pre‐
with the addition of an E.
admission clinics in determining a patient’s fitness
The ASA system correlates with mortality, as out-
but there are studies demonstrating increased
lined in Table 2.2 that details the outcome of
patient satisfaction as well as a decrease in hospital
732,704 patients.
length of stay.
Risk scoring systems lack sensitivity and specific-
APACHE
ity when applied to individuals. Assessment by an
First introduced in 1979, the Acute Physiology And anaesthetist in a pre‐admission clinic allows any
Chronic Health Evaluation (APACHE) system was scoring system to be used as an adjunct to informa-
developed to measure the severity of illness in intention obtained through clinical assessment of each
sive care patients. It consisted of both acute physi- individual patient. The three objectives of an anaes-
ological abnormalities as well as a chronic health thetic preoperative assessment are firstly to identify
evaluation measure. This was updated in 1985 with the risk of the patient developing an adverse out-
APACHE II with a reduction in the physiological come. The second is to assess any comorbidities
values from 34 to 12 as well as adding a points that may be optimised prior to surgery. The third
score for diminished physiological reserve due to objective is to individualise perioperative manage-
immune deficiency and ageing as well as chronic ment to attempt to minimise any remaining adverse
cardiac, pulmonary, renal or liver disease. Further outcomes.
There are a number of common comorbidities Neurological risk assessment

that should be assessed to minimise surgical risk.
There are a number of risk factors for cerebrovas-
cular complications in the postoperative period
Cardiac disease
that include age, cerebrovascular disease, hyperten-
Ischaemic heart disease is the commonest cause of sion, atrial fibrillation and the type of surgery.
serious cardiac adverse outcomes at the time of sur-
gery. There is a greater risk amongst patients with a Haematological risk assessment
past history of myocardial infarction, particularly
A past history of deep venous thrombosis, pulmo-
within 3–6 months. The presence of angina is less
nary embolism or haematological disorders (i.e.
clear as a marker of increased risk but congestive
protein C and S deficiency) increases the risk of
cardiac failure has consistently been found to be an
thromboembolism in the postoperative period.
indicator of worse outcomes.
There are a number of investigations that can be
Operative risk in the elderly
used to assess cardiac risk, the commonest being an
electrocardiogram. Non‐invasive assessments of Operative risk is greater in the elderly, with a two to
reversible cardiac ischaemia that may allow optimi- five times greater risk of death in comparison with
sation prior to surgery include exercise electrocar- younger patients. In general, elderly patients have a
diogram, radionuclide stress cardiac imaging and lower reserve when challenged by a surgical procedure
stress echocardiography. or complication. In the original National Confidential
Enquiry into Patient Outcome and Death (NCEPOD)
Respiratory disease released in 1987, 79% of perioperative deaths
occurred in the over‐65 age group, although that only
Patients with pulmonary disease are at risk of peri-
represented 22% of the surgical population.
operative complications such as hyperreactive air-
ways, prolonged ventilation, atelectasis, pneumonia
and respiratory failure. The site of the surgical inci- Summary
sion is important in determining risk due to impair-
ment of pulmonary function. Median sternotomy, Assessment of surgical risk is a key component to
upper abdominal incisions and thoracotomy are both preoperative surgical and anaesthetic care.
associated with the greatest risk. The assessment of surgical risk is critical in provid-
Pulmonary function tests are the main investiga- ing consent as well as for identifying those at risk
tion for assessment of pulmonary disease and treat- who can be optimised prior to surgery or managed
ment of reversible airway disease may be required in an appropriate environment to allow for the best
prior to surgery. possible outcome.
Renal risk assessment

Acute renal failure after surgical procedures is Further reading
associated with a higher mortality rate. Many ter-
tiary referral hospitals also have large nephrology Burnand KG, Young AE, Lucas J, Rowlands BJ, Scholefield J
services and surgical procedures on patients with (eds) The New Aird’s Companion in Surgical Studies,
3rd edn. Edinburgh: Elsevier Churchill Livingstone, 2005.
end‐stage renal failure are common. Again optimi-
Paterson‐Brown S (ed.) A Companion to Specialist
sation of the biochemical consequences of renal
Surgical Practice: Core Topics in General and
failure with preoperative renal dialysis is often Emergency Surgery, 6th edn. Edinburgh: Elsevier, 2018.
required for those patients with end‐stage renal
failure.
MCQs
Hepatic risk assessment
Select the single most appropriate answer to each
There are a number of risk assessments for chronic
question. The correct answers can be found in the
liver disease, including the Child–Pugh classifica-
Answers section at the end of the book.
tion and the Model for End‐stage Liver Disease
(MELD). Patients with liver failure are at a high 1 Discussion of the risks of a surgical procedure
risk of death even following basic surgical proce- should include:
dures so management in a specialist centre is a the side effects
required to reduce the risk of an adverse outcome. b likely complications
2: Assessment of surgical risk 17
c failure of the proposed surgery to achieve the b can be adequately assessed by electrocardiogra-
desired outcome phy alone
d the potential outcome if no action is taken c is not required if the patient continues to smoke
e all of the above d is only required for high‐risk cardiac surgical
patients
2 The American Society of Anesthesiologists (ASA) e may involve assessment of reversible cardiac
risk scoring system: ischaemia with radionuclide stress cardiac
a consists of 12 acute physiological abnormalities imaging or stress echocardiography
as well as a chronic health evaluation measure
b was designed for assessment of critically ill 4 Operative risk in patients over 65 years of age is:
intensive care patients a no greater than for younger patients
c can be adjusted according to various different b dependent on regular aspirin intake
surgical procedures c greater than younger patients
d is a 6‐point classification system for assessment d only a greater risk if surgery is required for
of patients prior to surgery trauma
e is assessed by the surgical team prior to surgery e greater for procedures performed under local
anaesthesia rather than general anaesthesia
3 Optimisation of cardiac ischaemia prior to surgery:
a is not necessary as ischaemic heart disease does
not increase operative risk
3 Anaesthesia and pain medicine
David Story
Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia
anaesthetists but also general practitioners, general

Introduction physicians, specialty physicians, pain medicine spe-
cialists, and nursing and allied health practitioners
Anaesthetists aim to minimise the risks of surgery
such as physiotherapists and cancer support nurses.
and anaesthesia for individual patients and provide
The anaesthetist’s assessment will include review-
optimal operating conditions leading to the best
ing assessments from others including the surgical
possible surgical outcomes. This requires direct
team and physicians. Anaesthetists want to know
patient care before, during and after surgery. The
about coexisting conditions (comorbidity), includ-
foundations of anaesthesia practice are general
ing (i) the nature and extent of the patient’s condi-
anaesthesia, regional anaesthesia, airway manage-
tion, (ii) the preferred treatment for this condition,
ment, perioperative medicine, pain medicine, resus-
and (iii) whether the patient is maximally opti-
citation crisis management, and safety and quality.
mised. Anaesthetists are experts in translating this
In contemporary anaesthesia these all centre on evi-
information into a perioperative plan. As with all
dence‐based cost‐effective practice.
good clinical assessment, anaesthetists consider
history, examination and tests.
The history often starts with a health question-
Before surgery
naire and then follow‐up questions during a face‐
to‐face meeting. Current medications and any
The aim of preoperative assessment is to identify
adverse reactions to medications, particularly aller-
and reduce risks and develop an individualised plan
gic reactions, are important. Another important
for the patient for the perioperative period (before,
area is prior experience of surgery and anaesthesia.
during and after surgery) to achieve the goals of
The initial focus of anaesthesia assessment is ABC
care, including being (ideally) cured of the surgical
(airway, breathing and circulation) or, more specifi-
condition (particularly cancer) and returning to the
cally, potential airway problems and respiratory or
best possible quality of life. About 20% of adult
cardiovascular dysfunction. Examination will focus
patients undergoing surgery and anaesthesia are at
on these areas. Tests will depend on the patient’s
high risk of postoperative complications, disability
comorbidity, age and planned surgery.
or death after surgery. Preoperative factors increas-
ing the risk of poor outcome range from severe
Airway
heart disease to severe anxiety to long‐term com-
plex pain syndromes. However, for patients with The aim is to detect potential airway problems
robust health, failure to achieve an expected return that may adversely affect the intraoperative and/
to competitive sport or full employment would be a or postoperative period. An increasing number of
poor outcome. patients have anatomy and disease states that may
make intraoperative airway management both
difficult and risky. Several factors (Box 3.1) are
Preoperative assessment associated with difficult endotracheal intubation,
All patients should receive timely appropriate pre- and which are also associated with difficult mask
operative assessment. Increasingly, this includes a ventilation and airway obstruction during
team approach including not only surgeons and sedation.
19
Box 3.1 Factors associated with Box 3.2 Preoperative fasting

difficulty of airway management recommendations
including during sedation
• For adults having an elective procedure, limited
• Previous difficult endotracheal intubation solid food may be taken up to 6 hours prior to
• Poor mouth opening anaesthesia and clear fluids may be taken up to 2
• Poor jaw advancement hours prior to anaesthesia. Clear fluids are regarded
• Prominent teeth as water, pulp‐free fruit juice, clear cordial, black
• Large tongue tea and coffee. This excludes particulate or milk‐
• Limited neck movement based drinks.
• Short, large neck (bull neck) • Prescribed medications may be taken with a sip of
• Extreme obesity water less than 2 hours prior to anaesthesia unless
• Obstructive sleep apnoea otherwise directed (e.g. oral hypoglycaemics and
• Large breasts anticoagulants).
Breathing (lung disease)

The greatest aspiration risk is for patients undergo-
The most common lung conditions are asthma,
ing emergency surgery particularly abdominal sur-
chronic obstructive pulmonary disease (COPD)
gery and in patients with known gastrointestinal
and recent cigarette smoking. Patients with severe
obstruction, pain requiring opioids, and active
asthma can deteriorate progressively or suddenly
vomiting. A relatively new aspiration risk is previ-
during the perioperative period; however, endotra-
ous gastric banding for obesity (see Chapter 18).
cheal intubation that directly stimulates the trachea
When possible, patients are fasted before surgery,
can be a strong trigger for asthma. Patients with
including all elective surgery, to reduce the risk of
COPD may have a reactive asthma‐like component
aspiration, particularly from large amounts of solid
as well as underlying structural lung disease.
material. Over the last 10 years fasting guidelines
Oxygen saturation on finger pulse oximetry of less
have been relaxed and fasting is not a barrier
than 92% on room air is associated with severe
for patients receiving their regular medications
lung disease and is a strong predictor of postopera-
(Box 3.2). However, patients with vomiting or gut
tive pulmonary complications including pneumo-
obstruction often need parenteral drug substitution
nia. The anaesthesia plan will depend on the
for important medications and pharmacist advice
severity of the asthma or COPD and the nature of
should be sought.
the surgery, with a preference for regional anaesthe-
sia where possible for patients with severe lung dis-
Cardiovascular
ease. Care of patients with severe disease will often
require coordination with optimisation plans, Symptomatic heart disease caries significant periop-
including preoperative oral steroids. While cigarette erative risk of complications and death, usually in
smoking is associated with perioperative respira- the first few days after surgery. Cardiac complica-
tory complications, smoking is also associated with tions are more common in patients with sympto-
surgical site infection and patients should be sup- matic ischaemic heart disease, heart failure or severe
ported with smoking cessation plans. Patients with heart valve disease. The aim of cardiac assessment is
very severe lung disease who may require prolonged to identify and minimise the risks of cardiac compli-
mechanical ventilation in the intensive care unit cations, such as myocardial injury after non‐cardiac
(ICU) need very careful consideration of whether to surgery including myocardial infarction, worsening
proceed with surgery. cardiac failure and significant arrhythmia notably
Another factor in respiratory assessment is aspi- atrial fibrillation. Previous stroke is a risk factor for
ration risk. Aspiration occurs when stomach con- both further stroke and cardiac complications.
tents are vomited or passively regurgitated and Several drugs for cardiovascular disease may be
contaminate the trachea and lower airways. withheld prior to surgery depending on individual
Aspiration can be acidic gastric fluid and/or bile circumstances, including opinion from the patient’s
and/or food. Aspiration may be associated with cardiologist, to reduce perioperative risks, for exam-
chemical pneumonitis, bacterial pneumonia or air- ple anticoagulants (including aspirin) to reduce
way obstruction and is a medical emergency. bleeding risk and some antihypertensives (ACE
Aspiration continues to be an important cause of inhibitors and angiotensin receptor blockers) to
complications and death before and after surgery. reduce the risk of persisting hypotension. Patients
3: Anaesthesia and pain medicine 21
with significant cardiovascular disease often require deficiency is with iron infusion. However, some
more intensive monitoring and intervention during patients will have functional anaemia, also known as
surgery, such as continuous monitoring of intra‐arte- anaemia of chronic disease, which is harder to treat.
rial pressure and use of vasopressors and then ongo-
ing care in high dependency or ICU after surgery. Postoperative nausea and vomiting
Other frequent and important comorbidities
include diabetes, anaemia and kidney disease. Postoperative nausea and vomiting (PONV) is called
the ‘big little problem’. PONV is common but usually
preventable and treatable. However, patients find
Diabetes
PONV distressing and may have delayed mobilisa-
Type 2 diabetes now affects up to 30% of surgical tion and prolonged admission and occasionally seri-
patients, with many previously undiagnosed. Poorly ous complications such as pneumonia. The Apfel risk
controlled diabetes in surgical patients is associated score for PONV includes four factors: (i) female sex;
with increased complications including infection. (ii) history of motion sickness or PONV; (iii) non‐
Patients with type 2 diabetes frequently have, or smoker; and (iv) planned postoperative opioid treat-
need to be screened for, chronic kidney disease and ment. The incidence of PONV ranges from 10% with
cardiovascular disease. Preoperative assessment no Apfel factors to 80% with four factors. Patients at
includes measurement of haemoglobin (Hb)A1c to high risk will often receive multimodal intraoperative
screen for diabetes in patients aged over 50 years anti‐emetic prophylaxis. Further, the anaesthesia and
and for diabetes control in those with known diabe- analgesia plan will have greater emphasis on non‐
tes. The key to managing diabetes in the periopera- opioid modalities, particularly regional analgesia.
tive period is to frequently measure the blood sugar Patients at high risk of PONV will also have regular
and respond to both hyperglycaemia and hypogly- rather than just rescue postoperative anti‐emetics.
caemia. To avoid hypoglycaemia, most oral diabe-
tes drugs will be withheld before surgery and insulin Pain
dosing will be modified. Many patients undergoing
major surgery will need temporary change to insu- Preoperative pain syndromes, particularly those
lin while in hospital in collaboration with the treated with opioids and often requiring orthopae-
diabetes team. dic or spinal surgery, require close attention and
specific planning. Multimodal pain management
plans with regional analgesia blocks should be
Chronic kidney disease
discussed with patients before surgery to outline
Even mild chronic kidney disease, defined as an risks and benefits. Chronic post‐surgical pain is
estimated glomerular filtration rate (eGFR) of less an under‐recognised complication of surgery.
than 60 mL/min per m2, carries a significant increase Approximately 10% of patients have chronic pain
in the risk of death after surgery. Patients should be (months to years) after major surgery, with about
on optimal treatment for the severity of their kid- one‐third of these patients having severe pain. This
ney disease. Maintaining adequate hydration is the incidence is higher in specific types of surgery,
most important strategy in reducing the risks of notably thoracic and breast surgery. Pain manage-
chronic kidney disease. ment plans individualised to the patient and the
surgery are important for reducing these risks.
Anaemia Some drugs, such as gabapentin, will need to be
started preoperatively. The pain plan must include
Identifying preoperative anaemia, and the underlying rescue for both poor postoperative pain control
cause, by measuring the haemoglobin and often and complications of pain control such as excessive
undertaking iron studies is important for risk mini- sedation.
misation. Some surgical conditions, particularly colo-
rectal cancer, have a high incidence of anaemia (see
Quantifying risk of complications
Chapter 1). Preoperative anaemia carries an increased
and mortality
risk of complications and mortality after surgery, in
addition to an increased risk of red cell transfusion While we often focus on the risks of complication,
which also carries risks of complications. The risks of death and disability, patient‐focused outcomes also
anaemia and transfusion may be reduced by identify- include pain, nausea and safe return to activities of
ing and managing preoperative iron deficiency and daily living, as well as anaesthesia‐specific risks
minimising intraoperative blood loss: patient blood including regional anaesthesia and adverse drug
management. The most effective way to treat iron reaction. Following comprehensive anaesthesia

Table 3.1 American Society of Anesthesiologists Physical Score (ASA‐PS).
ASA‐PS class Definition Examples
ASA I Healthy Healthy, non‐smoking, minimal alcohol use

ASA II Mild systemic disease Current smoker, well‐controlled hypertension, or mild
asthma
ASA III Severe systemic disease Poorly controlled diabetes, active hepatitis, or moderate
reduction of left ventricular ejection fraction
ASA IV Severe systemic disease that is a constant Ongoing cardiac ischaemia, sepsis, end‐stage cirrhosis
threat to life
ASA V A moribund patient who is not expected Examples include ruptured abdominal aneurysm, or gut
to survive without the operation ischaemia with septic shock
Source: https://www.asahq.org/
http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=2ahUKEwjX__
LSmLPeAhWlTt8KHRBzDX0QFjAAegQICBAC&url=http%3A%2F%2Fwww.asahq.org%2F~%2Fmedia%2Fsites
%2Fasahq%2Ffiles%2Fpublic%2Fresources%2Fstandards‐guidelines%2Fasa‐physical‐status‐classification‐system.
pdf&usg=AOvVaw2VpwTL1ioJ7‐XXfFM7Smwq Reproduced with permission of American Society of
Anesthesiologists.
assessment, patients should be allocated a score using

Box 3.3 Example of calculating risks
the American Society of Anesthesiologists Physical
for patients and related decisions
Score (ASA‐PS) (Table 3.1). This single‐variable score
is a remarkably strong predictor of postoperative Risk calculation for a 74‐year‐old woman for elective
complications and mortality. However, increased partial colectomy with colostomy using the American
accuracy can be achieved by including other risk College of Surgeons Risk Calculator
factors for complications and mortality such as • If assessed as ASA 2 (e.g. has hypertension), risk of
increasing age, frailty and emergency surgery. Risk death within 30 days of surgery is at least 0.5%
calculators, such as the American College of Surgeons and risk of complications is 20%. This patient is
online risk calculator (Box 3.3), allow quantitative suitable for ward care.
risk assessment of complications and mortality, usu- • If assessed as ASA 4 (e.g. has diabetes, cardiac
ally the risk of dying within 30 days of surgery (30‐ failure and chronic renal impairment), risk of death
day mortality). Patients with a 5% or greater risk of is at least 5% and risk of complication 35%.
30‐day mortality require higher levels of specialised Clinicians should strongly consider critical care
care including admission to ICU after surgery. Patients admission after surgery.
with a 5% risk of mortality are likely to have a risk of • If assessed as ASA 4, frail and having emergency
major complications exceeding 20% and risk of poor surgery (a growing number of patients), risk of
death is 13% and risk of complications 42%. The
functional recovery. Increasingly, in assessing the
goals of care should be discussed with the patient
goals of care these high‐risk patients undergo more
(and family) and some may decide for supportive
limited surgery or non‐surgical treatment.
care only or limitations on medical treatment if she
deteriorates after surgery.
Intraoperative care
block) and general anaesthesia, all of which have
The intraoperative care plan will depend on the
many additional options.
nature and extent of the surgery and the patient.
The broad aspects of anaesthesia are one or more
of pain relief, sleep or sedation, no memory (amne-
Intravenous access
sia), muscle relaxation and stable physiology, par- For many procedures intravenous access is predomi-
ticularly haemodynamic stability. The fundamental nantly used to administer drugs to provide appropri-
keys to safe anaesthesia are appropriate intrave- ate and safe anaesthesia, with fluid therapy being a
nous access and control of the airway. minor component. The small cannulas (blue, 22G,
The broad options for anaesthesia involve one or 0.41 mm diameter) have a maximum flow rate of
more of the following: local anaesthesia, sedation, about 30 mL/min but because flow is related to the
regional anaesthesia (spinal, epidural or nerve fourth power of the radius, a large cannula (orange,
3: Anaesthesia and pain medicine 23
14G, 1.6 mm diameter) has 10 times the flow (300 some supplemental oxygen due to respiratory
mL/min). Flow is enhanced in cannulas sited in larger depression or in order to wash out carbon dioxide
veins. For adult trauma patients, the standard of care and to reduce claustrophobia under drapes.
is two 16‐gauge cannulas in large cubital fossa veins Contemporary supplemental oxygen is often accom-
with a total flow of up to 400 mL/min (2 × 200 mL/ panied by continuous monitoring of expired carbon
min). This would be similar to intravenous access for dioxide. This safety measure detects hypoventilation
major surgery. Long catheters placed in central veins and airway obstruction due to apnoea.
(central lines), particularly the internal jugular vein,
are used for reliable and robust intravenous access
for drugs that could cause harm if they passed into Postoperative pain medicine
interstitial tissue through damaged peripheral veins
or if the drugs were suddenly stopped. Such drugs All anaesthetists, and many surgeons, are trained in
include potent vasoconstrictors whose sudden cessa- acute pain medicine. Advanced pain medicine is
tion can lead to severe shock and where extravasa- now a medical speciality with many practitioners
tion can lead to tissue necrosis. Central lines also also being anaesthetists. Good pain control after
allow easy venous blood sampling for analysis and surgery is a central part of postoperative care. The
for measurement of central venous pressure. most important cause of chronic post‐surgical pain
is severe acute postoperative pain.
Intraoperative monitoring Pharmacological therapy will be combined with
strategies such as physiotherapy and proactive
The most important intraoperative monitor is the
nursing care to effectively and efficiently return the
pulse oximeter, which allows continuous non‐
patient to the best possible function and recovery
invasive measurement of blood oxygen saturation
from their surgical condition. Other aims include
and heart rate. Falling oxygen saturation is most fre-
minimising the risks of pain therapies for the indi-
quently due to inadequate ventilation or inadequate
vidual and the spread of drugs of addiction (par-
inspired oxygen in patients who are anaesthetised
ticularly opioids) into the broader community.
but spontaneously breathing. Other fundamental
Collaboration with an anaesthetist‐led acute pain
monitoring includes ECG to detect changes or
service greatly facilitates these aims. Further, acute
abnormalities in heart rate and rhythm, and blood
pain medicine is more complex at extremes of age
pressure monitoring with either intermittent non‐
and in those with complex comorbidity, those suf-
invasive cuff measurements (usually the brachial
fering from opioid tolerance or dependence, obese
artery) or continuous invasive arterial monitoring
patients and those with complex pain syndromes.
(usually the radial artery).
While anaesthetists will usually plan and estab-
Contemporary anaesthesia machines can per-
lish a postoperative pain management plan, ward
form extensive electronic monitoring of multiple
clinicians need to measure a patient’s pain, often
patient and machine variables. In addition to the
with a 0–10 visual analogue scale and alter the plan
fundamental monitoring previously outlined,
if patients have poor pain control or side effects,
anaesthesia machines monitor inspired and expired
particularly excess sedation. Postoperative care also
gases (oxygen, carbon dioxide and anaesthetic
involves weaning from analgesia as appropriate
gases). Further, anaesthesia machines have complex
and moving the patient to oral pain relief appropri-
alarm systems that enhance safety monitoring indi-
ate for community discharge and subsequent cessa-
vidualised to the patient and procedure. Modern
tion. Chronic post‐surgical pain is an important
machine ventilators allow both full mechanical
complication after surgery. While some operations,
ventilation and assisted spontaneous ventilation.
particularly surgery via thoracotomy, carry a major
Depth of anaesthesia can be routinely monitored
risk of chronic post‐surgical pain, one in ten patients
with specialised EEG, and depth of muscle relaxa-
will have chronic pain after abdominal surgery.
tion with neuromuscular monitoring
Multimodal analgesia aims to combine the bene-
fits of different mechanisms to treat pain to provide
Oxygen therapy and airway interventions
high‐quality pain relief and minimise side effects.
Intraoperative airway interventions range from sup- The following list gives an indication of the postop-
plemental oxygen via nasal prongs through to erative analgesic options that can be individualised
endotracheal intubation. Even patients undergoing to patients and operations.
procedures under local anaesthesia and sedation, • Paracetamol: regular paracetamol is an effective
such as minor plastic surgery, or those undergoing foundation for multimodal analgesia. With appro-
major surgery under spinal anaesthesia may require priate dosing paracetamol has minimal side effects.
• Non‐steroidal anti‐inflammatory drugs arrhythmias and cardiac arrest but are dose
(NSAIDs): these drugs form the next tier of anal- related and rare with contemporary practice.
gesics. While being very effective analgesics,
NSAIDs can increase the risk of bleeding and Further reading
acute kidney injury. For most patients the bene-
fits greatly outweigh these relatively rare risks. American College of Surgeons. Surgical Risk Calculator.
• Opioids: morphine has been a mainstay of pain Available at https://riskcalculator.facs.org/RiskCalculator/
relief for centuries. In contemporary practice National Institute for Health and Care Excellence.
morphine is administered in many ways: oral, Routine Preoperative Tests for Elective Surgery. Nice
subcutaneous, intramuscular, intravenous, epi- Guideline NG45. London: NICE, 2016. Available at
dural and spinal. Many patients receive mor- https://www.nice.org.uk/guidance/ng45
Schlug SA, Palmer GM, Scott DA, Halliwell R, Trinca J.
phine via patient‐controlled analgesia (PCA) that
Acute pain management: scientific evidence, fourth edi-
aims to empower the patient and reduce risks. All
tion, 2015. Med J Aust 2016;204:315–17.
routes of morphine administration carry the risk Thilen SR, Wijeysundera DN, Treggiari MM. Preoperative
of life‐threatening respiratory depression and consultations. Anesthesiol Clin 2016;34:17–33.
death. Hospital protocols aim to minimise these
risks. However, far more frequent complications
include nausea, constipation and itch. Other fre- MCQs
quently used alternative opioids are fentanyl and
Select the single most appropriate answer to each
oxycodone. Tramadol is an atypical opioid with
question. The correct answers can be found in the
less respiratory depression, constipation and
Answers section at the end of the book.
potential for abuse. However, tramadol can have
important drug interactions that can limit its use,
1 A fit and healthy patient having their anterior
including a serotonin syndrome with some anti-
cruciate ligament repaired:
depressants. There is a strong trend towards min-
a has no cardiopulmonary perioperative risks
imising use of opioids around the time of surgery
b is American Society of Anesthesiologists Society
to reduce the frequency of in‐hospital opioid
Physical Status 1
complications (nausea and vomiting, constipa-
c will require minimal analgesia
tion and itch), reduce long‐term opioid use and
d will require a postoperative critical care bed and
reduce community opioid abuse.
prolonged hospital stay
• Ketamine: this drug acts on different receptors
e is likely to have obstructive sleep apnoea
from the opioids and provides complementary but
different analgesia and is opioid sparing. Ketamine 2 Anaesthesia assessment:
infusion is often introduced for inadequately a is usually just before induction of anaesthesia
treated pain after major surgery and for patients b requires blood tests
at significant risk with opioid analgesia. The major c excludes patients with complex pain syndromes
complication with ketamine is hallucinations. d requires history, examination and further tests
• Anticonvulsants: gabapentin and pregabalin are e is independent of surgical assessment
two anticonvulsants used to treat chronic as well
as acute pain from nerve injury, which can occur 3 Which of the following risk factors for postopera-
in many types of surgery. These drugs are also tive nausea and vomiting (PONV) is incorrect?
opioid sparing and reduce opioid side effects. a old age
• Local anaesthetics: increasingly, patients on b gender
wards have infusions of local anaesthetic through c previous nausea and vomiting
specialised catheters placed by anaesthetists that d non‐smoking
provide direct analgesia to major nerves and e use of opioids
nerve plexuses, or wound catheters placed by sur-
geons. Epidural infusions are still used in some 4 Opioids:
major thoracic and abdominal surgery, usually on a are the foundation of all pain management plans
an individualised basis. These infusions may pro- b have excitation as a major side effect
vide better postoperative analgesia, less opioid c cause diarrhoea
use and less PONV, itch and sedation than only d can be administered by several routes
using systemic analgesia. The most important side e are contraindicated for patients taking
effects of local anaesthetics are fitting, cardiac paracetamol
4 Postoperative management
Peter Devitt
Department of Surgery, University of Adelaide and Royal Adelaide Hospital, Adelaide,
South Australia, Australia
anaesthetist by the end of the procedure. In check-

Introduction ing the charts of the patient after the procedure,
care will be taken that these and any other medica-
Good postoperative management will have started
tions required are prescribed and administered.
before the procedure with appropriate counselling
These may include antibiotics (prophylactic or ther-
and preparation (see Chapter 1). This preparation
apeutic), sedatives, anti‐emetics and anticoagulants.
will have included an assessment of fitness for the
procedure and identification and management of
Monitoring
any risk factors. The patient will have been provided
with a clear explanation of the procedure (emer- Depending on the nature of the procedure and the
gency or elective), the risks and benefits, and the underlying state of health of the patient, the vital
likely outcome. This will have included a description signs (blood pressure, pulse and oxygen saturation)
of what the patient should expect in terms of short‐ will be measured and recorded regularly. If an arte-
and long‐term recovery from the procedure, possi- rial catheter has been inserted, blood pressure and
ble complications and the necessity for any drains, pulse readings can be observed on a monitor con-
stomas, catheters or other bits of tubing, the details stantly. The intensity and frequency of monitoring
of which would be alien to most of the population. will be maximal in the recovery room and this level
The anticipated length of time in hospital will have of scrutiny maintained if the patient is in an inten-
been discussed, as well as details of how long it will sive care or high‐dependency area.
take to make a full recovery from the procedure and Measurement of the central venous pressure may
how long the patient will be away from or unable to be required for patients with poor cardiorespira-
participate in their usual activities. The patient will tory reserve or where there have been large volumes
have been reassured about pain control measures of fluid administered or major fluid shifts are
and, perhaps most difficult of all, the doctor will expected.
have tried to ensure that the patient’s expectations The patient chart will also record all fluid that
match those of the health professional. has been given during and since the operation,
This chapter will focus on the care of the patient in together with fluid lost. Ideally, these figures will
the immediate postoperative period, up until the time have been balanced by the end of the procedure, so
of discharge from hospital. The immediate and short‐ that the duty of the attending doctor will be to
term needs of the patient and care to be provided will monitor ongoing losses (digestive and urinary
depend on the magnitude and type of surgery. tracts, drains, stomas) and replace these. The nor-
mal daily fluid and electrolyte requirements will
also be provided. If there has been major fluid shifts
or if renal function is precarious, a urinary catheter
Immediate management of the patient will be inserted and regular (hourly) checks made
of fluid losses. Serum electrolytes and haematologi-
Pain management
cal values will be checked frequently, again the fre-
Pain relief is of paramount importance (see quency depending on any abnormalities present
Chapter 3) and an appropriate drug regimen will and the magnitude of any fluid and electrolyte
have been prescribed by the surgeon and/or replacement.
25
Mobilisation Prophylaxis against venous

thromboembolism
Early mobilisation is encouraged. Unless there are
specified orders to the contrary, all patients are This is a key part of the management of any hospi-
encouraged to get up and move around as much talised individual, particularly the surgical patient.
as their underlying condition will allow. Obvious A risk analysis will have been performed preopera-
exceptions to this policy include patients with epi- tively (see Chapter 1) and depending on the nature
dural catheters and those with severe multiple of the procedure and the individual’s risk, some
injuries. The aim of early mobilisation is to form of chemoprophylaxis may be started in the
encourage good pulmonary ventilation and to postoperative period. This will require day‐to‐day
reduce venous stasis. For those who cannot mobi- monitoring and for major procedures, such as hip
lise, physiotherapy should be provided to help joint replacement or many cancer operations, the
with breathing and measures taken to either prophylaxis may be continued after discharge from
increase venous flow (pneumatic calf compression hospital. For patients being managed in intensive
devices) or reduce risks of deep vein thrombosis care settings and who, for various reasons, will
(heparin). The timing of any planned heparin have limited or no mobility, intermittent mechani-
administration will depend on the nature of the cal calf compression will be used in addition to
procedure and the risks of haemorrhage from that chemoprophylaxis.
procedure.
Enhanced recovery after surgery (ERAS)
Communication programs
When problems arise, they are frequently com- These structured programs are starting to replace
pounded by a failure of communication. Whilst traditional surgical practices, with implementation
the doctor’s duty of care is to the patients them- of protocols for early postoperative feeding, early
selves, the needs of the relatives must be taken mobilisation and more effective pain control meas-
into account. Simple things – which are often for- ures. Evidence now exists showing that these ERAS
gotten – include a reassuring telephone call to the systems can significantly reduce length of hospital
nearest relative after a procedure, informing them stay and complications rates, with overall reduction
(usually in general terms) of how the procedure in healthcare costs.
went. Whilst this is most obvious in the paediatric
setting, the same principles should be followed Respiratory care
with adult healthcare. The patients themselves
In the otherwise fit and healthy patient, maintenance
will seek some form of reassurance in the immedi-
of respiratory function is usually not a problem, par-
ate postoperative period. They will want to know
ticularly if there is optimal management of pain.
how the procedure went and how they are pro-
Even with upper abdominal or thoracic procedures,
gressing. They will also want reassurance that all
most patients will require little respiratory support
the tubes, lines and equipment to which they are
provided they are able to mobilise themselves and
attached are quite normal and not an indication
breathe unimpeded by pain. When assistance is
of impending disaster. Ideally, this will have been
required simple breathing exercises, with or without
discussed with them prior to the procedure. Any
the help of a physiotherapist, is usually sufficient.
unexpected findings or complications encoun-
Mechanical ventilation may be required in the early
tered during the procedure should be discussed
phase of recovery from a particular procedure. This
with the patient. The timing and detail of this dis-
can vary from prolonged endotracheal intubation, to
cussion is a matter of fine judgement and may be
intermittent positive pressure ventilation, to supple-
best done in the presence of the patient’s relatives
mental oxygenation by face mask or nasal prongs. In
and by the individual who performed the
these instances the patient may require prolonged
procedure.
monitoring in an intensive care or high‐dependency
unit with regular assessment of oxygen saturation
(pulse oximetry and arterial blood gas analysis).
Further care in the postoperative period For less fit patients, and particularly those with
chronic obstructive pulmonary disease (COPD), the
This covers the time from recovery from anaesthe- risks of respiratory failure will be considerable and
sia and initial monitoring to discharge from measures such as epidural local anaesthesia will be
hospital. Wound care is discussed in Chapter 6. employed. Control of pain, attention to regular
4: Postoperative management 27
hyperinflation (inhalation spirometry and physio-

Table 4.1 Electrolyte concentrations.
therapy) and early mobilisation are the keys to pre-
venting respiratory complications. Electrolyte Extracellular fluid Intracellular fluid
(mmol/L) (mmol/L)
Fluid balance Sodium 135 10

Potassium 4 150
The three principles of management of fluid bal-
Calcium 2.5 2.5
ance are:
Magnesium 1.5 10
• correct any abnormalities Chloride 100 10
• provide the daily requirements Bicarbonate 27 10
• replace any abnormal and ongoing losses. Phosphate 1.5 45
Ideally, any abnormalities will have been identi-
fied and corrected before or during the surgical
procedure. In the calculation of a patient’s fluid relatively simple regimen is 1 L of 0.9% saline and
requirements, there is a distinction to be made 1–2 L of 5% dextrose solution.
between the volume required to maintain the Both these solutions are isotonic with respect to
body’s normal functions and that required to plasma. The electrolyte solution contains the basic
replace any abnormal losses. The normal mainte- electrolyte requirements (154 mmol/L of sodium
nance fluid requirements will vary depending on and 154 mmol/L of chloride) and the total volume
the patient’s age, gender, weight and body surface can be adjusted with various amounts of dextrose
area. solution. Potassium can be added as required.
Other solutions (e.g. Ringer’s lactate) may contain
Basic requirements a more balanced make‐up of electrolytes, but are
rarely needed for a patient who is otherwise well
The total body water of a 70‐kg adult comprises
and only requires intravenous fluids for a few days.
45–60% of body weight. Lean patients have a
In the immediate postoperative period there is an
greater percentage of their body weight as body
increased secretion of antidiuretic hormone (ADH),
water and older patients a lesser proportion. Of the
with subsequent retention of water. In an adult of
total body water, two‐thirds is in the intracellular
average build, maintenance fluids can be restricted
compartment and one‐third is divided between
to 2 L per day with no potassium supplements until
plasma water (25% of extracellular fluid) and
a diuresis has occurred. This is not an absolute rule,
interstitial fluid (75% of extracellular fluid).
and potassium supplements can be given early, pro-
Therefore, a lean individual weighing 70 kg would
vided the patient has normal renal function.
have a plasma water of 3 L, an interstitial volume
Fluid and electrolyte replacement is that required
of 11 L and an intracellular volume of 28 L, making
to correct abnormalities. Volume depletion and
a total volume of 42 L.
electrolyte abnormalities are relatively common in
The normal daily fluid requirement to maintain a
surgical patients, particularly those admitted with
healthy 70‐kg adult is between 2 and 3 L. The indi-
acute illnesses. Volume depletion usually occurs in
vidual will lose about 1500 mL in the urine and
association with an electrolyte deficit, but can occur
about 500 mL from the skin, lungs and stool. Loss
in isolation. Reduced fluid intake, tachypnoea,
from the skin will vary with the ambient
fever or an increase in the ambient temperature
temperature.
may all lead to a unilateral volume loss. This will
The electrolyte composition of intracellular fluid
cause thirst and dehydration, which may progress
(ICF) and extracellular fluid (ECF) varies
to a tachycardia, hypotension and prostration. In
(Table 4.1). Sodium is the predominant cation in
severe cases there may be hypernatraemia and
ECF while potassium predominates in the ICF. The
coma. Intravenous administration of 5% dextrose
normal daily requirements of sodium and potas-
is used to correct the problem.
sium are 100–150 mmol and 60–90 mmol, respec-
More often volume depletion is accompanied
tively. This will balance the daily loss of these two
by an electrolyte deficit. Excessive fluid and elec-
cations in the urine.
trolyte may be lost from the skin (e.g. sweating,
burns), the renal tract (e.g. diabetic ketoacidosis)
Replacement
and the gastrointestinal tract (e.g. vomiting, ileus,
If an otherwise healthy adult is deprived of the nor- fistula, diarrhoea). There is considerable scope for
mal daily intake of fluid and electrolytes, suitable abnormal fluid losses in a surgical patient, par-
intravenous maintenance must be provided. One ticularly after a major abdominal procedure.
Table 4.2 Approximate electrolyte concentrations.
Sodium Potassium Chloride Bicarbonate Hydrogen

Secretions (mmol/L) (mmol/L) (mmol/L) (mmol/L) (mmol/L)
Salivary 50 20 40 50 —
Gastric 50 15 120 20 70
Duodenal 140 5 80 — —
Biliary 140 10 100 40 —
Pancreatic 140 10 80 80 —
Jejuno‐ileal 130 20 105 30 —
Faeces 80 10 100 25 —
Diarrhoea 100 30 50 60 —
There may be pooling of fluid at the operation nasogastric intubation to decompress the stomach
site itself, an ileus might develop, fluid could be after surgery for intestinal obstruction. Sump
lost through a nasogastric tube or drains, and drains are used to irrigate sites of contamination or
there might be increased cutaneous loss if there is infection.
a high fever. Drains can act as a point of access for infection,
The source of fluid loss will determine the type of and whilst this may be of little consequence if the
electrolyte lost. There is considerable variation in tube has been placed to drain an abscess cavity, all
the electrolyte content of different gastrointestinal efforts are made to reduce contamination of any
secretions (Table 4.2). Loss from the upper diges- wound. There is increased use of closed drainage
tive tract tends to be rich in acid, while loss from systems and dressings around drains are changed
the lower tract is high in sodium and bicarbonate. regularly. Any changes to tubes or bags on drains
Thus, patients with severe and prolonged vomiting must be carried out using aseptic techniques. Once
from gastric outlet obstruction may develop a met- a drain has served its purpose, it should be removed.
abolic alkalosis. The longer a drain stays in situ, the greater the risk
While the management of maintenance fluid of infection.
requirements can often be done on a daily basis, the The contents and volumes discharged through a
fluid and electrolyte replacement needs of an drain must be recorded. Large volumes, such as
acutely ill surgical patient is likely to be more those from the gastrointestinal tract, may need the
involved and necessitate close monitoring and equivalent amount replaced intravenously.
adjustment. Clinical assessment and appreciation
of the types of fluid loss will give an approximate
guide to the scale of the problem, but regular bio- Gut function
chemical electrolyte estimations will be required to
Some degree of gut atony is common after abdomi-
determine the precise composition of what needs to
nal surgery, particularly emergency surgery. The
be replaced. In most instances, measurement of
condition is usually self‐limiting and of little clini-
plasma electrolyte concentrations will provide suf-
cal consequence. There are three conditions that
ficient information, but occasionally it may be nec-
can produce massive gut dilatation and pose seri-
essary to estimate the electrolyte contents of the
ous problems for the patient:
various fluids being lost.
• gastric dilatation
• paralytic (small intestine) ileus
Drains and catheters • pseudo‐obstruction (large intestine).
Drains serve a number of purposes. They may be
Gastric dilatation
inserted into an operative site or into a wound as it
is being closed to drain collections or potential Gastric dilatation is rare and when it occurs tends
collections. Drains may also be put into the chest to be associated with surgery of the upper digestive
cavity to help the lungs re‐expand. They may be tract. It may occur suddenly 2–3 days after the
put into ducts and hollow organs to divert secre- operation and is associated with massive fluid
tions or to decompress that structure. Examples of secretion into the stomach, with the consequent
decompression include insertion of a tube into the risk of regurgitation and inhalation. Treatment is
common bile duct after duct exploration or by insertion of a nasogastric tube and
decompression of the stomach. Unfortunately, frequency in the patient undergoing an emergency

when gastric dilatation does occur, often the first procedure. The preoperative assessment will have
indication of the problem is a massive vomit and judged the individual’s risk and measures that
inhalation after the dilatation has occurred. By then might need to be taken to minimise respiratory
the damage is done and the value of a nasogastric problems (see Chapter 1). Apart from any comor-
tube at this stage is questionable. Traditionally, bidities, such as COPD, the likely cause of a patient’s
nasogastric tubes were used routinely for patients hypoxaemia will vary with the time of onset
following laparotomy, particularly in the emer- (Box 4.1).
gency setting. However, the nasogastric tube is Measures must be taken to minimise the risks of
often the patient’s major source of irritation and postoperative pulmonary complications, including
discomfort in the postoperative period and its rou- judicious use of pain medications, where local
tine use is gradually being abandoned. wound infiltration or nerve blocks may be more
appropriate than systemic measures. Early mobili-
Paralytic ileus sation and encouragement to cough and breathe
deeply must be actively promoted.
Paralytic ileus is less sinister and more common. In
Depending on the initial state of respiratory
the acutely ill patient who has undergone surgical
function and the degree of deterioration, the patient
intervention for peritonitis, paralytic ileus may be
may require anything from supplemental oxygen
present from the first postoperative day. Otherwise,
supplied by face mask to endotracheal intubation.
it tends to make its presence felt about 5 days after
A Pco2 above 45 mmHg, a Po2 below 60 mmHg
operation, and the patient may have been making
and a low tidal volume all indicate that mechanical
an apparently uneventful recovery. Abdominal dis-
ventilation will be required. Once appropriate ven-
tension occurs and the patient may vomit. Oral
tilatory support has been achieved, the cause of the
fluid restriction should be instituted and intrave-
respiratory failure can be addressed.
nous replacement may be required. Most cases
resolve spontaneously. Occasionally a prokinetic
Wound failure
agent may be considered.
Provided the surgical procedure has a minimal risk
Pseudo‐obstruction of infection (see Chapter 9) and has been performed
in an uneventful manner in a low‐risk patient, then
Classically, pseudo‐obstruction occurs in the
the chances of problems with the wound are mini-
elderly patient who has recently undergone sur-
mal and most such wounds can be left undisturbed
gery for a fractured neck of femur. The condition
is also often seen where there has been extensive
pelvic or retroperitoneal injury and sometimes the
condition appears to be more related to the use of Box 4.1 Factors contributing to
opiate analgesia rather than the type of surgery postoperative hypoxaemia
itself. The atony, with abdominal distension and
absence of bowel function, tends to occur 2–3 Immediate
days after surgery (or from the time the injury was Respiratory depression (anaesthetic agents, opioids)
sustained). Pseudo‐obstruction is often mistaken Within first 24 hours
for mechanical obstruction and the dilatation of Established respiratory disease (e.g. COPD)
the colon and caecum can be massive. If the condi- Obesity
tion does not resolve spontaneously, colonoscopic Excessive sedation
decompression is usually successful. Occasionally, Opiates
surgical intervention is required to prevent caecal Aspiration
perforation. Pneumothorax
Between days 2 and 5

Infection
Diaphragmatic splinting (secondary to abdominal
Important postoperative complications
distension)
Pleural effusion
Respiratory complications
Acute respiratory distress syndrome
Deterioration or impairment of respiratory func-
After day 5
tion is the commonest and more important postop- Pulmonary embolus
erative complication, occurring with greatest
until the patient leaves hospital. If there are identifi- dissection in subcutaneous tissues (e.g. mastec-
able risks the wounds may need to be attended to tomy) or where lymphatics may be damaged (e.g.
regularly. The problems that are likely to occur groin dissections). The seroma may not appear a
with wounds relate to: week after the procedure. Seromas will lift the skin
• discharge of fluid off the underlying tissues and impede wound heal-
• collection of fluid ing. They also make fertile ground for infection.
• disruption of the wound. Seromas should be aspirated under sterile condi-
Risk factors that may contribute to these prob- tions and the patient warned that several aspira-
lems include those that: tions may be required as the seroma may
• increase the risk of infection (see Chapter 9) re‐collect.
• increase the risk of wound breakdown.
There are general and local factors that increase
Confusion
the risk of breakdown of a wound. General factors
include those that interfere with wound healing, Confusion in surgical patients is common and has
such as diabetes mellitus, immunosuppression, many causes. Often the confusion is minor and
malignancy and malnutrition. Local factors include transient and does not need treatment. The patient
the adequacy of wound closure, infection and any- is typically elderly, has become acutely ill and in
thing that might put mechanical stress on the pain, is removed from the security and familiarity
wound. For example, abdominal wound failure is a of their home surroundings, is subject to emergency
potential problem in the obese, and in those with surgery and more pain, is put in a noisy environ-
chest infections, ascites or ileus. ment with strangers bustling around and is sleep‐
In the early stages of wound healing any abnor- deprived. These factors alone would make many
mal fluid at the wound site is likely to discharge otherwise healthy individuals confused. Add to that
rather than collect. The fluid may be blood, serous recipe the deprivation of the patient’s regular medi-
fluid, serosanguinous fluid or infected fluid of vary- cations (particularly alcohol), the upset to their
ing degrees up to frank pus. As discussed elsewhere body biochemistry, the presence of hypoxia and a
in this chapter, the discharge of blood from a wound variety of postoperative medications such as opi-
may have all sorts of consequences for the patient, oids, and it becomes understandable that some
which will vary from prompt opening of the neck degree of confusion is very common in the postop-
wound of a patient with a primary haemorrhage erative period. Confusion combined with restless-
after a thyroidectomy to evacuation of a haema- ness, agitation and disorientation is referred to as
toma after a mastectomy. delirium.
Serous fluid may be of little significance and be Important causes of confusion include:
the result of a liquefying haematoma from within • Sepsis (operative site, chest, urinary tract)
the depths of the wound. However, a serosan- • Hypoxia (chest infection, pulmonary embolus,
guinous discharge from an abdominal or chest pre‐existing pulmonary disease)
wound may herald a more sinister event, particu- • Metabolic abnormalities (hyponatraemia, hyper-
larly if it occurs between 5 and 8 days after the glycaemia/hypoglycaemia, acidosis, alkalosis)
operation. The discharge may have been preceded • Cardiac
by coughing or retching. Such a wound is in immi- • Hypotension (haemorrhage, dehydration)
nent danger of deep dehiscence with evisceration. • Cerebrovascular event
Should such an event occur, the wound must be • Drug withdrawal (alcohol, opiates, benzo-
covered in sterile moist packs and arrangements diazepines)
made to take the patient to the operating room for • Drug interaction (opiate sedation)
formal repair of the wound. • Exacerbation of pre‐existing medical conditions
Collections in and under a wound may be blood, (dementia, hypothyroidism).
pus or seroma. As mentioned, the rapidity with When a patient does become confused in the
which a haematoma appears and any pressure postoperative period, it is important to ensure that
effects such a haematoma may cause will determine no easily correctable cause has been overlooked.
its treatment. Collections of pus must be drained. Confusion is often secondary to hypoxia, where
Depending on its proximity or distance from the chest infection, over‐sedation, cardiac problems
skin surface, an abscess may be drained by opening and pulmonary embolism need to be considered.
the wound or inserting (under radiological control) Other important causes to consider include sepsis,
a drain into a deeper‐lying cavity. Seromas tend to drug withdrawal, metabolic and electrolyte distur-
occur where there has been a large area of bances and medications.
The management of the confused patient will operation is common and may reflect little more
include a close study of the charts, seeking informa- than the body’s metabolic response to injury.
tion on any coexisting disease (particularly cardi- A fever that is evident between 5 and 7 days after
orespiratory), drug record, alcohol consumption an operation is usually due to infection. While pul-
and the progress of the patient since the operation. monary infections tend to occur in the first few
Current medications should be noted, together with days after surgery, fever at this later stage is more
the nursing record of the vital signs. likely to reflect infection of the wound, operative
If possible, try to take a history and examine the site or urinary tract. Cannula problems and deep
patient. Ensure that the patient is in a well‐lit room vein thrombosis (DVT) should also be considered.
and give oxygen by face mask. Attention should be A fever occurring more than 7 days after a surgi-
focused on the cardiorespiratory system, as this cal procedure may be due to abscess formation.
may well be the site of the underlying problem. Apart from infection as a cause of fever, it is impor-
Some investigations may be required to help deter- tant to remember that drugs, transfusion and brain-
mine the cause of the confusion. These might stem problems can also produce an increase in body
include arterial blood gas analysis, haematological temperature.
and biochemical screens, blood and urine cultures, A careful history, review of the charts and physi-
a chest X‐ray and an electrocardiogram (ECG). cal examination will usually determine the cause of
Most patients with postoperative confusion do not the fever. The next stage in management will depend
require treatment other than that for the underlying on the state of health of the patient. The fever of a
cause. However, the noisy violent patient may need septic process, which has led to circulatory collapse,
individual nursing care, physical restraint or seda- will require resuscitation of the patient before any
tion. Sedation should be reserved for patients with investigation. Otherwise, appropriate investiga-
alcohol withdrawal problems, and either haloperidol tions may include blood and urine cultures, swabs
or diazepam should be considered in such circum- from wounds and drains, and imaging to define the
stances. Most hospitals have clearly defined proto- site of infection.
cols for the management of patients going through Treatment will depend on the severity and type of
alcohol withdrawal. These correlate the anxiety, vis- infection. The moribund patient will require resus-
ual disturbances and agitation of the patient with the citation and empirical use of antibiotics, the choice
degree of monitoring and sedation required. varying with the likely source of infection. Surgical
or radiological intervention (e.g. to drain an
abscess) may be required before the patient
Pyrexia
improves. However, the well patient may have anti-
The normal body temperature ranges between 36.5 microbial therapy deferred until an organism has
and 37.5°C. The core temperature tends to be been identified (e.g. Gram stain or culture).
0.5°C warmer than the peripheral temperature.
Thus an isolated reading of 37.5°C has little mean-
ing by itself and needs to be viewed in context with
Deep vein thrombosis and pulmonary
the other vital signs. Changes in temperature and
embolism
the pattern of change are more important. A tem- These complications can still occur despite prophy-
perature that rises and falls several degrees between laxis (see Chapter 1). Presentation of DVT may be
readings suggests a collection of pus and intermit- silent (60%) or as a clinical syndrome (40%). If
tent pyaemia, while a persistent high‐grade fever is suspected on clinical grounds (painful, tender and
more in keeping with a generalised infection. swollen calf), duplex ultrasonography is the investi-
Fever can be due to infection or inflammation. In gation of choice, with a sensitivity and specificity
determining the cause of the fever the following greater than 90%. In cases of suspected pulmonary
should be considered: embolism, a CT pulmonary angiogram is the appro-
• the type of fever priate investigation.
• the type of procedure which the patient has The treatment of DVT has now moved from
undergone unfractionated heparin infusion to subcutaneous
• the temporal relationship between the procedure low‐molecular‐weight heparin. This is maintained
and the fever. until the patient is fully anticoagulated on warfarin
Perhaps the most useful factor in trying to estab- and the latter is continued for 3–6 months to mini-
lish the cause of a patient’s fever is the relationship mise the risk of further thrombosis and the devel-
between the time of onset of the fever and the pro- opment of complications (see Chapters 73 and 75).
cedure. Fever within the first 24 hours of an A caval filter might have to be considered,
particularly for clot extending into the iliofemoral considered due to hypovolaemia until proven
segments. otherwise.
The treatment of a pulmonary embolus will
depend on the severity of the event. A relatively Hyponatraemia
minor episode, with no cardiovascular compro-
mise, can be managed with heparinisation, whereas Any reduction in the sodium concentration in the
a more serious embolus may need surgical interven- ECF may be absolute or secondary to water reten-
tion (embolectomy) or use of a fibrinolytic agent. tion. Loss of the major cation from the ECF leads to
a shift of water into the ICF. Any clinical manifesta-
Oliguria tion will reflect the expansion of the ICF (e.g. con-
Oliguria is a common problem in the postoperative fusion, cramps, and coma secondary to cerebral
period and is usually due to a failure by the attend- oedema) or the contraction of the ECF in absolute
ing medical staff to appreciate the volume of fluid hyponatraemia (e.g. postural hypotension, loss of
lost by the patient during the surgical procedure and skin turgor).
in the immediate postoperative period. For example, Hyponatraemia due to a total body deficiency of
the development of an ileus will lead to a large vol- sodium ions is an unusual scenario in the postop-
ume of fluid being sequestered in the gut and this erative surgical patient. Any hyponatraemia that
‘loss’ not being immediately evident. Before the occurs tends to be due to dilution and is caused by
apparent oliguria is put down to diminished output the administration of an excessive amount of water.
of urine, it is important to ensure that the patient is While this is a fairly frequent biochemical finding,
not in urinary retention. Such an assessment can be it rarely leads to any clinically significant problem.
difficult in a patient who has just undergone an Any hyponatraemia secondary to dilution may
abdominal procedure. If there is any doubt, a uri- also occur with inappropriate ADH secretion. The
nary catheter must be inserted. Alternately, most trauma of major surgery will produce an increase in
wards are now equipped with ultrasonographic ADH secretion and intravenous fluid must be
devices capable of providing an accurate estimation administered judiciously in the immediate postop-
of the bladder content. erative period. A safe rule of thumb is to restrict the
Diminished output of urine may be due to: patient to 2 L per day of maintenance fluid until a
• poor renal perfusion (pre‐renal failure due to diuresis has been established. Hyponatraemia can
hypovolaemia and/or pump failure) usually be corrected by the administration of the
• renal failure (acute tubular necrosis) appropriate requirements of isotonic saline. If the
• renal tract obstruction (post‐renal failure). patient has a severe hyponatraemia and associated
In the assessment of a patient with poor urine mental changes, an infusion of hypertonic sodium
output (<30 mL/h), these three possible causes must solution may be required.
be considered. Major surgery with large intraopera-
tive fluid loss and periods of hypotension during Hypernatraemia
the procedure might suggest renal tissue damage
Hypernatraemia in the postoperative patient is a
(acute tubular necrosis), while severe peritonitis
less common problem than hyponatraemia. Any
with large fluid shifts and no hypotension would be
hypernatraemia is usually relative rather than abso-
more in keeping with inadequate fluid
lute and occurs secondary to diminished water
replacement.
intake. Patients with severe burns or high fever may
The treatment of oliguria depends on the cause.
also develop hypernatraemia. An increase in the
Pre‐renal hypovolaemia is treated by fluid replace-
plasma sodium concentration will lead to a loss of
ment, while poor output secondary to pump failure
ECF volume and relative intracellular desiccation.
requires diuretic therapy and perhaps medications
The first clinical manifestation is thirst and if the
(e.g. inotropes, antiarrhythmics) to improve cardiac
hypernatraemia is allowed to persist, neurological
function. To give a hypovolaemic patient a diuretic
problems (e.g. confusion, convulsions, coma) may
in an attempt to improve urine output may be
ensue. Treatment is by administration of water by
counterproductive and detrimental.
mouth or intravenous 5% dextrose.
In acute renal failure the oliguria will not respond
to a fluid challenge. Management demands accu-
Hyperkalaemia
rate matching of input to output, monitoring of
electrolytes and even dialysis. With normal renal function, severe and life‐
In summary, most cases of postoperative oliguria threatening hyperkalaemia is rare. High concentra-
are secondary to hypovolaemia, and should be tions of potassium in the ECF can be associated
with cardiac rhythm disturbances and asystole. mechanical problem or local sepsis. Generalised
Hyperkalaemia may occur in severe trauma, sepsis bleeding may reflect a coagulation disorder and
and acidosis. Emergency treatment of arrhythmia‐ may be manifest by the oozing of fresh and unclot-
inducing hyperkalaemia consists of rapid infusion ted blood from wound edges and with bleeding
of a 1 L solution of 10% glucose with 25 units of from sites of cannula insertion.
soluble insulin. The insulin will help drive potas- Most cases of reactionary (and primary) haemor-
sium into the cells and the glucose will help coun- rhage are from a poorly ligated vessel or one that has
teract the hypoglycaemic effect of the insulin. At the been missed, and are not secondary to any coagula-
same time 20 mmol of calcium gluconate can be tion disorder. The bleeding point may go unnoticed
given to help stabilise cardiac membranes. If an during the operation if there is any hypotension, and
arrhythmia has already developed, the calcium glu- makes itself known only when the patient’s circulat-
conate should be given before the dextrose and ing volume and blood pressure have been restored to
insulin. Sodium bicarbonate (20–50 mmol) can be normal. The bleeding in secondary haemorrhage is
given if the patient is acidotic. If the level of potas- due to erosion of a vessel from spreading infection.
sium is not too high, an ion‐exchange resin (reso- Secondary haemorrhage is most often seen when a
nium) can be given. These resins can be administered heavily contaminated wound is closed primarily, and
by enema and they exchange potassium for calcium can usually be prevented by adopting the principle of
or sodium. Alternatively, the patient may be dia- delayed wound closure.
lysed (peritoneal or haemodialysis). In the manage- Postoperative haemorrhage can also be classified
ment of hyperkalaemia it is obviously as important according to its clinical presentation. The most com-
to treat the cause as it is to treat the effect. mon forms are wound bleeding, concealed intra-
peritoneal bleeding, gastrointestinal haemorrhage
Hypokalaemia and the diffused ooze of disordered haemostasis.
The approach to management will depend on the
Low levels of potassium in postoperative patients are overall condition of the patient and the assessment
common but hypokalaemia is rarely so severe as to of the type of bleed. A stable patient with a localised
produce muscle weakness, ileus or arrhythmias. blood‐soaked dressing will be managed differently
Patients with large and continuous fluid loss from the from a hypotensive patient with 2 L of fresh blood
gastrointestinal tract are prone to develop hypoka- in a chest drain, who in turn will be managed differ-
laemia. If potassium supplements are required they ently from a patient with a platelet count of 15 ×
may be given either orally or intravenously. If by the 109/L and fresh blood oozing from all raw areas.
latter route, the rate of infusion should not exceed In the first case the tendency might be to apply
10 mmol/h. Faster rates may precipitate arrhythmias another dressing in an attempt to achieve control by
and should only be undertaken on a unit where the pressure. A more positive approach is to remove the
patient can be monitored for any ECG changes. dressing and inspect the wound. In most instances, a
single bleeding point can be identified and con-
Haemorrhage trolled. In the next case, the patient has a major
bleed and this is probably from a bleeding vessel
The management of haemorrhage in the postopera-
within the operative site. Return to the operating
tive period may be approached in several ways. In
room and formal re‐exploration must be seriously
broad terms, bleeding may be classified as either
considered. In the third case, the prime problem is an
localised or generalised. If the former, it may be
anticoagulation defect requiring urgent correction.
classified as follows:
The diagnosis of postoperative haemorrhage is a
• primary (bleeding which occurs during the
clinical one, based on knowledge of the surgical pro-
operation)
cedure, the postoperative progress and an assess-
• reactionary (bleeding within the first 24 hours of
ment of the patient’s vital signs. The blood loss may
the operation)
not always be visible and could be concealed at the
• secondary (bleeding occurring at 7–10 days after
operative site or within the digestive tract. The treat-
the operation).
ment of postoperative haemorrhage depends on the
If localised, the bleeding is usually related to the
severity of the bleed and the underlying cause.
operative site and/or the wound. Occasionally, the
Hypovolaemia and circulatory failure will demand
bleeding may be at a point removed from both
urgent fluid replacement and consideration of the
these areas, for example gastrointestinal haemor-
likely cause and site of bleeding. Careful considera-
rhage from a stress‐related gastric erosion. Bleeding
tion must be given to control of localised haemor-
from the wound site is usually indicative of a
rhage and whether re‐operation is warranted.
Vomiting the dissection is difficult and the appendix is

found to be perforated and 100 mL of purulent
The causes of vomiting after surgery are many, and
fluid aspirated from the abdominal cavity, after
can be best determined by establishing the relation-
which a saline lavage is performed. The patient
ship between onset of vomiting and the time of the
cannot void postoperatively and requires a
operation. The two most common causes of post-
urinary catheter for 24 hours. He is kept on
operative vomiting are drug‐induced and gut atony.
intravenous antibiotics for 3 days and then
Vomiting that occurs in the immediate postoper-
discharged home on a 5‐day course of oral
ative period is usually drug related. If it is due to the
antibiotics. Three days after discharge he goes to
effects of anaesthesia, vomiting will usually settle
see his family doctor complaining of persistent
within 24 hours. Current anaesthetic techniques
diarrhoea. Which one of the following is the most
and modern anti‐emetics have rendered nausea and
likely diagnosis?
vomiting a relatively minor postoperative problem
a resolving paralytic ileus
for most patients.
b prostatitis
Vomiting that occurs several days after operation
c Clostridium difficile enteritis
may still be drug related, but in this instance is usu-
d leakage from the appendix stump
ally due to an opiate rather than an anaesthetic
e urinary tract infection
agent. Vomiting may be secondary to gut stasis, and
this atony is usually self‐limiting. If prolonged, a
3 A 56‐year‐old man undergoes a laparoscopic
prokinetic agent can be effective.
cholecystectomy 2 days after being admitted
If vomiting starts 7 days or so after abdominal
with acute cholecystitis. At operation some acute
surgery, a mechanical cause for the problem should
inflammatory changes are found around the
be considered.
gallbladder, which makes the procedure more
difficult than expected. A drain is placed in the
Further reading gallbladder bed at the end of the operation. The
following day the patient does not look well and is
Abeles A, Kwasnicki RM, Darzi A. Enhanced recovery complaining of right upper quadrant pain. He has
after surgery: current research insights and future direc- required regular morphine overnight to control his
tions. World J Gastrointest Surg 2017;9:37–45. pain. His blood pressure is 120/70 mmHg, heart
Marcantonio ER. Delirium in hospitalized older adults. rate 110 beats/min and temperature is 38.2°C. He
N Engl J Med 2017;377:1456–66.
has passed 100 mL of urine since the operation. On
pulmonary auscultation there are bibasal crackles
MCQs and there is guarding in the right upper quadrant.
Nothing has come out of the drain. Which one of
Select the single correct answer to each question. the following would be the most likely explanation
The correct answers can be found in the Answers for his current problem?
section at the end of the book. a aspiration pneumonia
b acute retention of urine
1 A previously well 56‐year‐old businessman is c bile leak
admitted with a perforated peptic ulcer and d duodenal perforation
undergoes surgery and repair of the perforation. He e pulmonary embolism
is making a satisfactory recovery but 3 days after
the operation becomes aggressive, shouting and 4 A 68‐year‐old man undergoes a semi‐elective
demands to be let home. He is still requiring laparoscopic cholecystectomy for acute cholecysti-
intravenous fluids for slow return of gut function. tis. The procedure is uncomplicated. Twelve hours
Which one of the following is the most likely later his blood pressure is 114/72 mmHg and his
explanation for his behaviour? urine output since operation has been 90 mL. He
a anxiety over work commitments has intravenous isotonic saline running at 80 mL/h.
b opiate toxicity Which one of the following is the most appropriate
c pneumonia next step in management?
d alcohol withdrawal a continue current management
e intravenous fluid overload b intravenous frusemide
c infusion of dopamine
2 A 21‐year‐old man undergoes a laparoscopic d infusion of noradrenaline
appendicectomy for appendicitis. At operation, e 1 L isotonic saline over 4 hours
5 Surgical techniques
Benjamin N.J. Thomson1 and David M.A. Francis2
1
University of Melbourne, Royal Melbourne Hospital Department of Surgery and Department of
General Surgery Specialties, Royal Melbourne Hospital, Melbourne, Victoria, Australia
2
Department of Urology, Royal Children’s Hospital, Melbourne, Australia and Department of Surgery,
Tribhuvan University Teaching Hospital, Kathmandu, Nepal
A face mask, which covers the nose and mouth,

Introduction prevents droplet spread of secretions and bacteria, is
worn for any invasive procedure and is changed after
This chapter reviews techniques used in surgical
each case. Eye protection in the form of plain plastic
practice and invasive procedures.
glasses or a visor attached to the face mask must be
worn to protect against droplet spray of infected
body fluids. Gloves are worn if there is a possibility of
The operating room (see also Chapter 12) coming into contact with patients’ body fluids. Clean
theatre attire, dedicated theatre shoes and a disposa-
The operating room is a dedicated area for surgical ble hair cover are worn while in the operating suite.
procedures and must be conducive to performing sur-
gery to the highest standards of safety for patients
and staff. The principal purpose of such a dedicated Aseptic techniques
area is to reduce the risk of infection of patients. The
operating room must be large enough for complex Joseph Lister, in 1865, first demonstrated the reduc-
procedures to be undertaken, for storage of appropri- tion in surgical site infections with disinfection
ate equipment, movement of staff, as well as the techniques. Aseptic techniques are clinical practices
maintenance of a sterile area around the operative that aim to prevent infection occurring in the
field. By changing the operating room air 20–25 times patient as a result of the surgical procedure by:
each hour at positive pressure relative to outside the • preparation and cleaning the patient’s skin with
room, low concentrations of airborne bacteria and antiseptic fluid before it is incised or punctured
particulate matter can be maintained. The number of • use of sterilised instruments, equipment or surgi-
people in the room and their movement should be cal materials which might come into contact with
minimised. Ambience within the operating theatre the operative field and surgical wound.
should be calm and professional, and procedures Personnel involved directly in the operative proce-
should be performed in a manner that is respectful to dure (surgeon, surgical assistant and ‘scrub’ nurse)
the patient and to all the staff involved. The air tem- wash their hands and forearms with antiseptic soap
perature should be such that inadvertent patient for 5 minutes before the first operation of the day
hypothermia does not occur. The operative field must and for 3 minutes before each subsequent case to
be well illuminated; surgeons sometimes wear a head reduce skin flora. More recently, alcohol‐based
light for procedures in body cavities that cannot be hand rubs have been developed that require appli-
illuminated easily by standard operating room lights. cation for 1 minute. Hands are dried with sterile
The surgeon’s assistant has the important role of towels, and a moisture‐impermeable sterile gown is
assisting and supporting the surgeon in the smooth worn. One or two pairs of sterile gloves prevent
conduct of operations. It is important to concen- transfer of bacteria from the surgeon’s hands to the
trate on the task at hand, to carry out the surgeon’s patient and also protect the surgeon from infected
instructions with speed and accuracy, to have a blood and body fluids from the patient.
sense of anticipation, and to notify the surgeon of After induction of anaesthesia, hair is removed
any potential problem during the operation. from the operative site by shaving with a razor
35
or electric clippers. The skin is cleansed with an anti-

Box 5.1 Methods of sterilisation
septic solution starting at the site where the incision
will be made and working away from the area, so Autoclave
that approximately 10–20 cm of skin around the Uses superheated steam at high pressure to reach a
incision site is prepared. The patient is covered with temperature of 121°C. Sterilisation is achieved when
sterile linen or impermeable drapes, leaving exposed droplets of superheated water evaporate immediately
only the cleansed area around the incision site, which upon reduction of pressure, thereby destroying
may be covered by a sterile adhesive plastic drape. microorganisms and leaving instruments dry. Most
surgical instruments and linen drapes are sterilised by
Surgical antiseptics autoclaving.
The commonest source of bacterial contamination Dry heat
in the operating room is from the patient. Therefore, Items which tolerate heat but not moisture can be
topical antiseptic agents are used to reduce the sterilised by dry heat, but it is less efficient and takes
number of skin organisms prior to any skin incision longer than autoclaving.
or puncture, and include the following.
Ethylene oxide gas
• Aqueous chlorhexidine (0.5%) is used to disin-
Takes several hours and is used for heat‐sensitive
fect mucous membranes and parts of the body
items such as endoscopes, electrical and optical
adjacent to structures which would be adversely
equipment and some plastics.
affected by more stringent antiseptics (e.g. the
skin around the eyes). Aqueous chlorhexidine is Glutaraldehyde
bactericidal and has low tissue toxicity. A 2% solution is used to sterilise equipment that can
• Cetrimide (2%) is bactericidal. tolerate moisture but not heat, such as urological
• Iodine‐based antiseptics, such as povidone iodine catheters, plastics and rubber.
10% (Betadine) and alcoholic iodine solution, Ionising radiation
destroy a wide range of bacteria, especially staph- Uses gamma rays and is particularly useful for
ylococci, by iodisation of microbial proteins. sterilising single‐use disposables such as plastics,
• Alcohol‐based (70%) antiseptics kill bacteria by dressings, scalpel blades and synthetic conduits.
evaporation.
• Chlorhexidine 2% can also be used in combina-
tion with 70% alcohol.
Hazards, other than those intrinsic to the anaes-
Sterility thetic and surgical operation, are organisational or
related to operating room equipment or the transfer
Anything that comes into contact with the surgical and positioning of the patient on the operating table.
wound must be sterile. The method of sterilisation
depends on the item being sterilised (Box 5.1). Organisational hazards
Universal precautions Organisational hazards should be entirely preventa-
The risk of transmission of infectious agents from ble. A full history and examination of the patient
patients to staff (and vice versa) is reduced by prac- must be made before surgery, including the past
tising universal precautions. Thus, it is assumed that medical history, drug history and allergies, so that
all patients harbour potentially dangerous patho- elementary errors are not made (e.g. unwittingly
gens (e.g. hepatitis C, HIV) no matter how innocu- operating on a patient with a pacemaker or who is
ous they appear, because carrier status cannot anticoagulated, or prescribing a drug to which the
definitely be excluded without repeated, expensive patient is allergic). Before surgery commences, the
and time‐consuming investigations. The principle of reason for and nature of the operation, together with
universal precautions is to establish a physical bar- its potential common and serious complications, and
rier between the patient and the carer to prevent the reasonable expectations from the procedure, are
direct contact with any potentially infected body discussed with the patient and family who are free to
fluid or tissue in either direction (Box 5.2). ask any questions. A consent or request for treat-
ment form, which states the nature of the operation
and the side on which the operation is to be per-
Hazards formed if the operation is a unilateral procedure, is
signed by the patient and the surgeon or deputy.
In addition to infection, there are many potential Once in the operating suite, a check is made to
sources of hazard in the operating environment. confirm that all the necessary safeguards have been
5: Surgical techniques 37
small point of contact (active electrode) through the

Box 5.2 Universal precautions
patient to a large contact site (indifferent electrode
Barrier protection or ‘diathermy plate’) to produce localised heat
Appropriate protective barriers are used during which coagulates protein. Diathermy produces
invasive procedures and handling contaminated (i) coagulation (haemostasis with a small amount
materials: gloves, face mask, eye shield, impermeable of adjacent tissue damage), (ii) cutting (tissue cut-
gown, shoe covers, hair cover. ting with minimal tissue damage), or (iii) fulgura-
tion (haemostasis with considerable tissue necrosis).
Minimising potential exposure
Potential dangers include electrocution, inadvertent
Decrease the risk of spreading potentially infected
burn to the patient at a remote site and to the sur-
body fluids by avoiding spillages, careful disposal of
geon, fire associated with pooled alcohol‐based
materials and equipment contaminated by body
fluids, having only essential personnel present during
antiseptics, explosion of flammable anaesthetic
invasive procedures, excluding personnel with open gases, and interference with the function of cardiac
wounds or abrasions, using impermeable dressings to pacemakers.
cover wounds, and using closed rather than open A variety of lasers with different wavelengths
drains. and effects on cells and tissues are used in surgical
practice for highly accurate tissue destruction (e.g.
Elimination of needlestick injuries
mucosal surgery, CNS tumours, dermatological
Do not handle uncapped needles, never re‐sheath
lesions, aerodigestive tumours), coagulating blood
used needles, and never remove a used needle from a
vessels (e.g. gastrointestinal tract, retinal photoco-
syringe. Use needles as little as possible. Immediately
agulation), and for photoactivation of intra‐tumour
dispose of used needles in a designated ‘sharps’
haematoporphyrin for malignant tumour destruc-
disposal container which has a one‐way opening.
tion (photodynamic therapy). Hazards include eye
Elimination of other penetrating injuries damage, explosion of anaesthetic gases, and shat-
Sharp objects (e.g. scalpels, needles) are transferred tering and destruction of other equipment.
between operating personnel in a ‘sharps dish’, not Limb tourniquets are used to provide a blood-
from hand to hand. Hand‐held needles are not used. less field in which to operate. The limb is ele-
Blunt suture needles are used where possible. Sharp vated and exsanguinated by a rubber bandage or
instruments are not placed on the operative field or
compressive sleeve, and the proximal tourniquet
anywhere on the patient. Alert personnel to the
inflated to 50 mmHg (upper limb) or 100 mmHg
presence of any sharp object in the operative field.
(lower limb) above systolic blood pressure. A tour-
niquet should not be kept inflated for more than
60–90 minutes. A record should be kept during the
performed for the patient. The World Health
operation of how long the tourniquet has been
Organization surgical safety checklist or variations
inflated. Tourniquet complications include arterial
are now mandatory in most Australian hospitals.
thrombosis, distal ischaemia, nerve compression
The checklist can be used at three stages: before the
and skin traction.
induction of anaesthesia (‘sign in’), before the inci-
sion of the skin (‘time out’) and before the patient
leaves the theatre (‘sign out’). The varied processes Positioning of the patient
in each hospital include checklists that ensure the
The patient is positioned on the operating table in
correct patient is having the correct procedure, the
such a way that the procedure is facilitated and the
correct site or side of the operation has been
airway can be protected. Pressure points are pad-
marked, that relevant equipment is available and
ded, and limbs are positioned so that peripheral
that the relevant imaging and clinical notes are
nerves, major blood vessels, joints and ligaments
available. At the start of each theatre list the ‘time
are not stretched or compressed. The anaesthetised
out’ for the first patients also includes an introduc-
patient must be in a stable position on the operat-
tion of all present in the theatre. Discussion of all
ing table and may need to be strapped in position
anticipated surgical and anaesthetic concerns are
with broad adhesive tape. There must be no contact
also discussed along with plans for prevention of
between the skin and any metallic surface because
deep venous thrombosis during and after theatre.
of the risk of diathermy burn and pressure necrosis.
Sections of the operating table can be angled so that
Equipment
the patient is optimally positioned for the particu-
Diathermy is used universally in surgical practice. lar procedure (e.g. flexed while lying supine or on
High‐frequency alternating current passes from a one side, head‐down, head‐up).
Endoscopy Endoscopic surgery
Endoscopy is performed by inserting a fibre‐optic There are two forms of endoscopic surgery that
telescope containing a light source and instrument both involve the insertion of a microchip video
channels into the gastrointestinal, respiratory and camera with a light source into the lumen or
urinary tracts. The operator undertakes the proce- through the wall of the aerodigestive tract into a
dure by manipulating the endoscope while viewing body cavity. The latter is performed through an
a video screen but occasionally the eyepiece of the incision in the wall of the gastrointestinal tract
instrument may be used. with placement of specially crafted surgical instru-
ments into a body cavity. For both techniques the
surgeon undertakes the procedure by manipulat-
Gastrointestinal endoscopy ing the instruments while viewing a video screen.
Endoscopy of the gastrointestinal tract allows the Some forms of endoscopic surgery utilise endo-
endoscopist to view the lumen of the oesophagus, scopic ultrasound for guidance of incisions or
stomach and proximal half of the duodenum placement of internal drains. Examples of endo-
(oesophagogastroduodenoscopy or upper gastro- scopic surgical procedures include resections of
intestinal endoscopy or gastroscopy), colon larger gastrointestinal tumours (endoscopic
(colonoscopy), rectum and distal sigmoid colon
mucosal resection), drainage of infected pancre-
(sigmoidoscopy), and distal rectum and anal canal atic collections into the stomach (endoscopic cyst‐
(proctoscopy). It is usually performed under seda- gastrostomy), oesophageal myotomy (per oral
tion. Intestinal endoscopy can also be performed at endoscopic myotomy or POEM), endoscopic sinus
laparotomy (enteroscopy) by making a small inci- surgery and natural orifice transluminal endo-
sion in the intestine and passing the endoscope scopic surgery (NOTES).
along the intestinal lumen. Procedures such as dila- The advantages of endoscopic or ‘closed’ surgery
tation of strictures, biospy and diathermy ablation are reduced postoperative pain and analgesic
of polyps, injection of adrenaline around bleeding requirements, earlier discharge from hospital and
gastric and duodenal ulcers, cholangiopancreatog- earlier return to normal function. However, many
raphy, removal of common bile duct calculi, biliary surgical procedures either cannot be undertaken
dilatation or stenting, injection of haemorrhoids endoscopically because of their very nature, or can-
and tumour phototherapy can be performed using not be completed endoscopically because of diffi-
fibre‐optic endoscopes. culty or patient safety, in which case the operation
is converted to an ‘open’ procedure. Some proce-
dures use endoscopic techniques to assist with the
Bronchoscopy procedure and an incision is made to either com-
The upper airway, trachea and proximal bronchi plete the operation or deliver the resected specimen.
can be inspected by bronchoscopy, which may be The range of endoscopically performed operations
performed under local or general anaesthesia. in many surgical specialties has increased enor-
Bronchoscopy is used for diagnosis (e.g. inspec- mously over the last 20 years.
tion and biopsy of lung tumours) or therapy (e.g.
removal of foreign bodies, aspiration of secre-
tions). Anaesthetists occasionally use the fibre‐optic Open surgery
bronchoscope to facilitate difficult endotracheal
intubation. Open surgery is the traditional or conventional
method of operating. In general terms, open surgery
involves making a surgical wound, dissecting tis-
Urological endoscopy
sues to gain access to and mobilise the structure or
The urethra (urethroscopy), bladder (cystoscopy) organ of interest, completing the therapeutic proce-
and ureters (ureteroscopy) can be inspected for dure, ensuring haemostasis is complete, and then
diagnostic purposes. Extensive therapeutic proce- closing the wound with sutures. Open surgery is
dures (e.g. resection of the prostate, diathermy and performed more with the hands and direct touch
excision of bladder tumours, extraction of calculi) than endoscopic procedures, and fingers may be
can be performed safely with far less morbidity used for ‘blunt’ dissection. The surgical wound
than the equivalent open procedures. accounts for much of the morbidity of open
surgery, particularly the cutting of muscle. The Orthopaedic surgery

range of open operations is extremely wide, as evi-
Large joints (e.g. knee, hip, ankle, shoulder, wrist)
denced by the procedures described throughout
can be inspected by arthroscopy. Therapeutic proce-
this book.
dures include removal of bone chips, cartilage exci-
sion and removal, and ligament repair. Arthroscopic
Minimally invasive surgery surgery has been enormously beneficial for ortho-
paedic patients and has allowed far more rapid
Minimally invasive surgery avoids the larger inci- return to function.
sions of open surgery to minimise morbidity.
Different types of microchip video cameras can be Robotic surgery
used to visualise the required cavity or space within Robotic surgery is a form of minimally invasive
the body. The cameras vary in size and their com- surgery where the surgeon is positioned remote to
plement of different angled lenses, which are either the patient but usually within the operating theatre.
fixed or manoeuvrable. Magnification of the image A robotic system operated by the surgeon is used to
often provides a superior view to that obtained at control the camera as well as the instruments that
open surgery. are placed through multiple ports. A surgical assis-
tant still makes the port site incisions and a theatre
Abdominal surgery nurse is scrubbed to change to robotic instruments
Laparoscopy refers to the technique of insufflat- when required. The robot is particularly useful for
ing the peritoneal cavity with gas, inserting a cam- work in cramped narrow spaces where robotic
era through most commonly a 10–15 mm suturing is far superior to laparoscopic suturing
subumbilical incision and inspecting the abdomi- techniques in such instances. The commonest exam-
nal contents. Usually additional ports are inserted ple of robotic surgery is radical prostatectomy with
through 5–10 mm incisions in the abdominal wall the robotic reconstruction of the bladder and ure-
and instruments (e.g. scissors, grasping devices, thra in a narrow male pelvis. Other common exam-
retractors, staplers, needle holders, energy devices) ples include partial nephrectomy and thoracic
are introduced and manipulated by the surgeon to surgery. However, nearly all abdominal, thoracic
perform the operation. Procedures such as chole- and some upper aerodigestive and cardiac opera-
cystectomy, gastric fundoplication, hiatus hernia tions have been described using robotic techniques.
repair, division of adhesions, appendicectomy, Recently, transaxillary breast, thyroid and parathy-
splenectomy, adrenalectomy, nephrectomy, oopho- roid surgery have also been described.
rectomy, tubal ligation, bariatric surgery and her-
nia repair can be undertaken laparoscopically
with less morbidity than if undertaken as an open Surgical methods
or conventional operation. Endoscopic surgery
has allowed some procedures to be undertaken as Surgical operations are performed by well worked
day cases, whereas the same procedure performed out, standardised steps which progress in logical
as an open operation would require an inpatient sequence. An operative plan is determined by the
stay of several days (e.g. cholecystectomy, hernia surgeon for every operation.
repair).
Surgical instruments
Thoracic surgery
There are literally thousands of surgical instru-
Thorascopy involves inserting a camera with a ments, some simple and others extremely complex,
light source and instruments into the thoracic cav- but each designed for a specific function. The sur-
ity. The technique is used diagnostically and thera- gical incision is made with a scalpel, which con-
peutically for procedures such as drainage of the sists of a reusable handle and a disposable blade.
thoracic cavity (haemothorax, pleural effusion and Scissors are used to cut other tissues and sutures,
empyema), lung biopsy, pleurodesis and excision of and for blunt dissection with the blades closed.
lung bullae. The mediastinum can be inspected and Diathermy is used for haemostasis and to cut
mediastinal lymph nodes can be biopsied by medi- through tissue layers beneath the skin. Tissues are
astinoscopy, which may prevent the need for an held with dissecting or tissue‐grasping forceps
exploratory thoracotomy. rather than the fingers. Hand‐held forceps either
have teeth for better grasping ability or are non‐ majority of cases of operative and postoperative
toothed for handling delicate tissues. Needle hold- bleeding are due to inadequate surgical haemostasis
ers are used to hold needles for suturing and rather than disorders of clotting and coagulation.
eliminate the need for hand‐held needles, and are Haemostasis is essential in order to prevent blood
therefore safer. They have a ratchet so that the nee- loss during surgery and haematoma formation
dle can be contained securely in the holder while postoperatively. Methods of surgical haemostasis
not in the surgeon’s hand. Retractors allow the include the following.
surgeon to operate in an adequately exposed field. • Application of a haemostatic clamp to a blood
Self‐retaining retractors keep the wound edges vessel and then ligation with a surgical ligature.
apart without the aid of an assistant. Retractors • Suture ligation of a vessel: under‐running a
held by the assistant provide tissue retraction in bleeding vessel with a figure‐of‐eight suture
awkward parts of the wound and in situations which is tied firmly.
where retraction of specific tissues is required so • Application around a blood vessel of small metal
that intricate parts of the operation can be per- U‐shaped clips that are then squeezed closed.
formed. A sucker is used to aspirate blood and • Diathermy coagulation.
body fluids from the operative field and to remove • Localised pressure for several minutes to allow
smoke created by the diathermy. There are many coagulation to occur naturally.
instruments designed specifically for surgical spe- • Application of surgical materials (e.g. oxidised
cialties and procedures. cellulose, Surgicel) which promote coagulation.
• Application of topical agents to promote vaso-
Incisions constriction (e.g. adrenaline) or coagulation (e.g.
thrombin).
Surgical incisions are made so that:
• Packing of a bleeding cavity with gauze packs as
• the operation can be undertaken with adequate
a temporary measure until definitive haemostasis
exposure of the area or structure of interest
can be achieved.
• the procedure can be performed and completed
safely and expeditiously
Sutures and wound closure
• the wound heals satisfactorily with a cosmeti-
cally acceptable scar. Sutures have been used to close surgical wounds for
Thus, incisions are to be of adequate but not exces- thousands of years, and initially were made from
sive length and, if possible, placed in skin creases, human or animal hair, animal sinews and plant
particularly when operating on exposed areas of material. Today, a wide variety of material is avail-
the body such as the face, neck and breast. Parallel able for suturing and ligating tissues (Box 5.3).
skin incisions (‘tram tracking’) and V‐ or T‐shaped Sutures are selected for use according to the
incisions are avoided because of ischaemia of inter- required function. For example, arteries are sutured
vening tissue and pointed flaps. together with non‐absorbable polypropylene or
polytetrafluoroethylene (PTFE) sutures, which are
Tissue dissection non‐thrombogenic, cause virtually no tissue reac-
tion and maintain their intrinsic strength indefi-
Ideally, surgical dissection should be performed
nitely so that the anastomotic scar (which is under
along tissue planes, which tend to be relatively
constant arterial pressure) does not stretch and
avascular. The aim is to isolate (mobilise) the
become aneurysmal. Skin wounds, for example, are
structure(s) of interest from surrounding connec-
sutured with either non‐absorbable sutures, which
tive tissue and other structures with the least
are removed after several days, or absorbable
amount of trauma and bleeding. Tissues should be
sutures hidden within the skin (subcuticular sutures)
handled with great care and respect and as little as
and which are not removed surgically but are
possible. Dissection is undertaken by using a scalpel
absorbed after several weeks.
or scissor (sharp dissection), a finger, closed scissor,
Sutures are available in diameters ranging from
gauze pledget or scalpel handle (blunt dissection),
0.02 to 0.50 mm. The minimum calibre of suture
or the diathermy. Gentle counter‐traction on tissues
should be used, compatible with its function. Non‐
by the assistant facilitates the dissection.
absorbable sutures are avoided for suturing the
luminal aspects of the gastrointestinal and urinary
Haemostasis
tracts because substances within the contained flu-
Surgical haemostasis refers to stopping bleeding ids (e.g. bile, urine) may precipitate on persisting
which occurs with transection of blood vessels. The sutures and produce calculi.
Box 5.3 Sutures
Substance Description* Duration† Trade name Uses
Plain catgut Nat, Multi, Ab 1–2 weeks — Subcutaneous fat

Chromic catgut Nat, Multi, Ab 2–3 weeks — Subcutaneous fat, gastrointestinal
and urinary tract anastomoses
Silk and linen Nat, Multi, Non Prolonged — Skin and cardiac sutures, ligatures
Stainless steel Nat, Mono, Non Prolonged — Sternum, skin and gastrointestinal
staples, orthopaedic wire
Polyglycolic acid Syn, Multi, Ab 3–4 weeks Dexon Gastrointestinal and urinary tracts,
muscle, fascia, subcutaneous fat
Polyglactin Syn, Multi, Ab 4–6 weeks Vicryl Gastrointestinal and urinary tracts,
muscle, fascia, subcutaneous fat
Polypropylene Syn, Mono, Non Indefinite Prolene Ophthalmology, vascular sutures,
abdominal closure, neurosurgery,
fascia, skin
Polyamide Syn, Mono, Non Years Nylon Abdominal and skin closure, hernia
repair
Polytetrafluoroethylene Syn, Mono, Non Indefinite Gore‐Tex Vascular anastomoses, hernia repair
(PTFE)
* Ab, absorbable; Mono, monofilament; Multi, multifilament; Nat, natural; Non, non‐absorbable; Syn, synthetic.
†
Time during which tensile strength is maintained.
The requirements of suture material are as • Monofilament or multifilament: monofilament

follows. sutures pass through tissues easily, are generally
• Tensile strength: the suture must be strong less reactive, and are more difficult to handle and
enough to hold tissues in apposition for as long knot securely. Multifilament sutures are braided
as required. or twisted thread, and are easier to handle and
• Durability: the suture must remain until either knot, but are more likely to harbour microorgan-
healing is advanced or indefinitely if the healed isms within the suture.
tissue is under constant pressure. Recently, cyanoacrylate adhesives (‘superglue’)
• Reactivity: tissue reaction (i.e. an inflammatory have been used to seal small leaks in blood vessels
response) allows absorbable sutures to be and vascular suture lines, and for closure of small
removed by phagocytosis but results in chronic superficial skin wounds. The adhesive polymerises
inflammation if non‐absorbable sutures remain and hardens rapidly on contact with tissues.
in situ.
• Handling characteristics: sutures must be easy to
grasp, handle and tie.
Surgical knots
• Knot security: sutures must be able to be tied effec-
tively so that knots do not come undone or slip. Knots are tied to ensure that ligatures and sutures
Sutures are classified as follows. remain in place and do not slip or unravel. The
• Absorbable or non‐absorbable: the rate of absorp- ability to tie a secure knot is a fundamental tech-
tion of absorbable sutures depends on their com- nique in surgery, and patients’ lives literally
position and their thickness. Disappearance of the depend on knot security (e.g. the knot in a ligature
suture occurs through inflammatory reaction, used to tie off an artery). Knot security depends on
hydrolysis or enzymatic degradation. friction between the throws of the ligature mate-
• Synthetic or natural material: sutures of natural rial, the number of throws used to tie the knot, the
(animal) origin are being phased out of surgical strength of the ligature material and the tightness
practice because of the very minimal risk of dis- of the knot. Usually, multiple throws are used to
ease transmission. A wide variety of synthetic secure the knot (e.g. two reef knots, one on the
suture materials are available. other).
Suturing Surgical drains

The technique of suturing depends on the tissue Drains are used widely in surgical practice to:
and wound being sutured. Sutures may be either • Remove blood or serous fluid, which would
continuous (e.g. subcuticular skin sutures, abdomi- otherwise accumulate in the operative area (e.g.
nal closure, vascular anastomosis) or interrupted wound drain)
(e.g. skin sutures, sternal wires). The function of • Provide a track or line of minimal resistance so
sutures is to hold the adjacent edges of sutured tis- that potentially harmful fluids can drain away
sues in apposition and to immobilise them in that from a particular site (e.g. drain placed into an
position so that wound healing (i.e. neovascularisa- intra‐abdominal abscess cavity).
tion, connective tissue ingrowth and collagen for- Several different methods of drainage may be used
mation) is facilitated. It is essential that sutures are depending on the required function.
not tied so tightly that the tissues encompassed by • Open drainage: a drain tube or strip of soft flex-
them become ischaemic. Skin sutures may be sup- ible latex rubber is placed so secretions or pus
ported by adhesive paper tapes. can drain along the track of the drain into gauze
Retention sutures (incorrectly referred to as ten- or other dressing covering the external end of
sion sutures) are used to close abdominal incisions the drain tube (e.g. drain placed in an abscess
that are thought to be at increased risk of dehiscence, cavity, drain placed prophylactically near a
and are inserted to encompass a large amount of fas- bowel anastomosis in case of subsequent anasto-
cial tissue and are placed 3–5 cm apart. Retention motic leak).
sutures have now been replaced by techniques using • Closed drainage: a tube is placed into an area or
lateral incisions of the abdominal wall, mesh recon- viscus to drain fluid contents into a collecting
struction and negative pressure wound devices. bag so that there is no contamination of the
Within the last two decades, stainless steel staples drained area from outside the system (e.g. chest
have been used to close skin wounds and to per- drain, urinary catheter, cholecystostomy drain).
form gastrointestinal anastomoses. Staples are • Closed suction drain: the drain tube is connected
quicker to use than sutures, but are relatively to a bottle at negative atmospheric pressure so
expensive and produce a worse cosmetic result for that fluid is sucked out of the area (e.g. wound
skin closure than subcuticular absorbable sutures. drain, drain under skin flaps).
It is important to note both the amount and the
type of fluid that drains. Large volumes of fluid
Suture removal drainage may need to be replaced as intravenous
fluids (e.g. duodenal fistula fluid). Depending on
Sutures are removed as early as possible to minimise
the particular situation, it may be necessary to cul-
the risk of infection and scarring, so long as tissue
ture drain fluid or send it for estimation of haemo-
healing is sufficiently advanced that the wound will
globin, creatinine, electrolytes, amylase or protein.
not open when the sutures are removed. Sutures are
A radiological contrast study may be performed
therefore removed at different times, depending on
along the drain tube, for example to estimate the
tissue and general patient factors (Box 5.4). For
size of a cavity being drained.
example, sutures are left in situ for a longer time in
Drain tubes are removed when they are no
patients who are immunosuppressed, malnourished,
longer required, for example when there is mini-
jaundiced or undergoing chemotherapy; in those
mal fluid being drained, or when a cavity being
who have renal failure; and in tissues judged to be
drained has contracted and is small. Drains are
relatively ischaemic, subject to increased stress and
removed simply by cutting the suture which
tension, and which have been irradiated.
anchors them to the skin and withdrawing the tube
from the patient.
Box 5.4 Timing of suture removal at
various sites
Venepuncture
Face 3–5 days Venepuncture involves removing blood from a super-
Neck (skin crease) 5–7 days ficial vein, usually in the antecubital fossa or dorsum
Scalp 7–10 days
of the hand, by inserting a needle attached to a
Abdomen 10 days
syringe or collection tube at negative pressure
Extremity 10–14 days
(Vacutainer system). A venous tourniquet is applied
Amputation stump 21 days
around the arm, which is hung in a dependent
position; the patient vigorously opens and closes the • Short‐term monitoring of central venous pressure.
hand, and the vein is gently patted to encourage A central venous catheter (CVC) may be inserted
venous dilatation. The skin is cleansed with antisep- into the internal or external jugular vein or the sub-
tic and the needle is inserted through the skin into the clavian vein. Temporary CVCs are made of semi‐
dilated vein at an angle of 30–45°. Once the required rigid Teflon, are approximately 25 cm in length
volume is aspirated, the tourniquet is released, the and, depending on their function, are between 1
needle withdrawn, the puncture site immediately and 4 mm in diameter and have one, two or three
covered with a cotton wool swab, and light pressure lumens. Long‐term CVCs are made of barium‐
applied for 1–2 minutes. The site is covered with an impregnated silastic and are quite flexible. They
adhesive dressing. Complications include bruising, have a Dacron cuff bonded to the part of the cath-
haematoma and, rarely, infection and damage to eter which lies subcutaneously and becomes incor-
deeper structures. Inadvertent needlestick injury to porated by fibrous tissue after several weeks so that
the venepuncturist is avoided by careful technique. organisms cannot track along the catheter from the
skin into the circulation.
Intravenous cannulation Some long‐term single‐lumen CVCs are availa-
ble with a small‐volume chamber attached to
Intravenous (i.v.) cannulation is used commonly for
the extravenous end of the catheter (Portacath,
administration of fluids and drugs. Superficial veins
Infusaport). The catheter and chamber are implanted
on the forearms and dorsum of the hands are used
subcutaneously after the vein is catheterised and can
for i.v. cannulation. Antecubital fossa veins are best
be accessed for chemotherapy or blood sampling by
avoided for cannulation because the elbow has to
inserting a needle into it through the skin.
be kept extended to avoid kinking of the cannula.
CVC insertion is best performed in an operating
Leg veins may have to be used in the absence of use-
theatre, under local or general anaesthesia, and
able upper limb veins. Cannulas have a soft outer
with ultrasound localisation of the central vein.
Teflon sheath attached to a hub, and a central hol-
The patient is placed in a supine, slightly head‐
low needle attached to a small chamber.
down position, and the surface anatomy of the
A suitable vein is identified as for venepuncture.
vein is marked. Aseptic technique is essential. A
Local anaesthetic cream is applied to the skin over-
hollow wide‐bore needle is inserted into the vein, a
lying the vein or local anaesthetic (1% lidocaine
guidewire is passed down the needle and the needle
without adrenaline) is injected intradermally next
is removed. The guidewire position is checked
to the vein after cleansing the skin with antiseptic.
radiologically. A plastic dilator is passed over the
The cannula (needle and sheath) is inserted through
guidewire to dilate a track for the catheter and is
the skin into the vein at an angle of 10–30°. The
then removed, and the CVC is passed over the
small chamber fills with blood when the needle is in
guidewire which is removed after the CVC is in
the lumen of the vein. The cannula is then advanced
place. A chest X‐ray is performed to check the final
into the vein. The needle is removed from the sheath
position of the CVC and also to ensure that a
and a closed three‐way tap or i.v. giving set is joined
pneumothorax or haemothorax has not occurred
to the hub of the sheath. The cannula is secured to
due to inadvertent puncture of the pleura or lung.
the skin with adhesive tape.
The catheter is sutured to the skin to prevent dis-
Intravenous infusion is painful when the infusate
lodgement and the exit site is dressed with an
is cold or contains irritants (e.g. potassium, calcium,
adhesive dressing.
drugs of low or high pH), or if the cannula pierces
Peripherally inserted central catheters are now
the vein wall and fluid extravasates subcutaneously.
placed under radiological guidance for the majority
Thrombophlebitis develops at the insertion site
of patients who require long‐term venous access for
after about 3 days, and i.v. cannulas should be re‐
parenteral nutrition or antibiotics, or for those
sited if infusions are required for longer periods.
patients with difficult peripheral venous access.
Central venous catheterisation

Percutaneous catheterisation of a central vein is
Further reading
used for:
• Short‐ or long‐term venous access when periph- Cochran A, Braga R (eds) Introduction to the Operating
eral veins are unsuitable or cannot be used Room. New York: McGraw‐Hill, 2017.
(e.g. prolonged fluid infusion, total parenteral Keen G, Farndon JR (eds) Operative Surgery and
nutrition, ultrafiltration, haemodialysis, plasma Management, 3rd edn. Oxford: Butterworth‐
exchange, chemotherapy) Heinemann, 1994.
d enables cholecystectomy to be performed as

MCQs day‐case surgery in some patients
e can only be used for part of an operation
Select the single correct answer to each question. The
correct answers can be found in the Answers section
3 Sutures:
at the end of the book.
a should be left in the skin for a minimum of 1 week
1 Universal precautions: b often need to be removed with local anaesthetic
a protect operating theatre staff from electric c must be tied tightly so that arterial inflow into
shocks tissues is not possible
b prevent polluted air from entering the operating d made of Prolene will dissolve
theatre e of all types must eventually be removed
c impose a physical barrier between patients and
carers 4 Surgical drains:
d are only to be used when operating on patients a are removed when they are no longer necessary
e protect only against bacterial pathogens b should always be removed the day after surgery
c are removed under general anaesthesia
2 Laparoscopic surgery: d are not necessary with modern surgical
a has a very limited role in general surgical practice techniques
b is inherently unsafe because the surgeon cannot e are required after the majority of general surgery
touch the structures being operated on procedures
c is associated with greater postoperative pain and
immobility
6 Management of surgical
wounds
Rodney T. Judson
University of Melbourne and Royal Melbourne Hospital, Melbourne, Victoria, Australia
seroma formation; and (iv) providing wound sur

Introduction veillance to detect and intervene if any signs of
complications develop. To achieve this aim a care
Surgery entails gaining access to deeper body struc
ful preoperative assessment is made based on clini
tures usually necessitating a surgical incision, which
cal history and examination supported by special
may be performed by a scalpel or the use of dia
tests as indicated. Intraoperative assessment as to
thermy. The final step in the surgical procedure is
the health and perfusion of the wound edges and
closure of the surgical incision (wound). Rapid
the extent of bacterial contamination informs deci
complication‐free healing is anticipated. Unfor
sions regarding the best wound closure technique.
tunately, infection of the wound, described as surgi
Decisions regarding the wound dressing are usually
cal site infection (SSI), remains the most common
made based on whether the wound is closed and
healthcare‐associated infection among surgical
appears dry or whether the wound is to be left
patients. While advances have been achieved in
open. Postoperative care is centred on continuing to
infection control practices, operating room design,
address those risks identified in the preoperative
sterilisation techniques and appropriate use of anti
assessment that are likely to affect wound healing.
biotics preoperatively and perioperatively, SSI
remains a common cause of morbidity and even
mortality. The development of an SSI increases hos Preoperative assessment
pital length of stay by approximately 7–8 days. SSIs
account for up to 16% of healthcare infections, of A number of important factors affect wound
which most are related to bowel surgery (10%) healing and these should be assessed and corrected
with fewer than 1% from orthopaedic procedures. preoperatively if possible.
Other wound complications that affect patient • Poor glycaemic control in diabetics is associated
recovery include haematoma formation and devel with a twofold increase in SSI.
opment of seromas, both of which increase the like • Smoking, with its effect on the cutaneous circula
lihood of wound infection. An SSI is also a common tion, increases the likelihood of SSI.
precursor to wound dehiscence or separation, • Obesity, with increased dead space in the wound,
which if involving the full thickness of the wound favours seroma formation and SSI.
may lead to evisceration of the abdominal contents • Malnutrition delays wound healing.
requiring urgent surgical intervention. Minimisation • Medications such as corticosteroids and immu
of these complications is achieved by (i) preopera nosuppressive drugs increase infection risk.
tive minimisation of any patient factors that might • Systemic anticoagulants increase haematoma for
impede wound healing; (ii) choosing the most mation and subsequent SSI.
appropriate wound closure technique, be that pri • Serious comorbidities, especially cardiorespira
mary wound closure or a method of delayed clo tory disease and decrease in oxygen saturation.
sure; (iii) selection of a wound dressing that will Steps should be taken to address any reversible
protect and support the wound while removing adverse factors if possible. In emergency situations
excessive fluid exudate and potentially reducing time may preclude any meaningful intervention,
45
which is reflected in an increased risk of SSI follow

ing urgent surgery. Persistent risk factors need to be
Preoperative wound preparation
considered when deciding on the best method of
wound management. Primary closure of wounds in
Skin care
the presence of adverse patient factors and bacterial Bathing or showering using soap the day before
contamination is associated with a high incidence surgery is recommended. Preoperative bathing or
of SSI, which delays healing and possibly results in showering using antiseptics has not shown any con
severe systemic sepsis. clusive reduction in postoperative SSI. Preoperative
hair removal such as shaving the day before surgery
may increase infection risk due to colonisation of
Classification of surgical wounds the resulting minor abrasions. If hair removal is
deemed necessary, this should occur immediately
Simple or complex prior to surgery.
The commonest surgical wounds are linear inci
sions involving the skin, subcutaneous tissue and Antibiotic prophylaxis
deeper fascial layers. These incisions are performed An important preoperative decision is the need for
using a sharp scalpel to gain access to deeper struc perioperative antibiotic coverage to reduce the like
tures which are the focus of the surgical procedure. lihood of development of an SSI. This decision is
Operations, especially for malignant disease, occa based on an assessment of the potential wound,
sionally require excision of the skin and subcutane whether any prosthetic material is to be implanted
ous tissues overlying the tumour. These complex at the time of surgery and the burden of patient
wounds may require complicated surgical tech risks factors.
niques to achieve wound closure. The consensus of opinion is that a clean incised
wound in a healthy patient performed in a well‐vas
Clean cularised area does not require antibiotic prophy
laxis. For all other wounds, when prosthetic
If the procedure is performed under sterile condi material is implanted and in patients with risk fac
tions and no contamination of the wound occurs, tors for SSI, preoperative antibiotics should be
the wound is described as a clean incised wound. used.
Such wounds have minimal bacterial contamina For greatest effectiveness antibiotics should be
tion and under ideal circumstances would be administered parenterally approximately 1 hour
expected to have a low SSI rate of 1–2%. prior to surgery to allow appropriate wound con
centration of the antibiotic at the time of the
Clean contaminated incision.
If the respiratory, alimentary, genital or urinary The choice of antibiotic depends on the suspected
tracts are entered under surgically controlled condi or anticipated nature of bacterial contamination.
tions and without unusual contamination, the Most hospitals have agreed antibiotic guidelines
wound is classified as a clean contaminated wound. based on local known bacterial risks. If in doubt
Such wounds would result from procedures includ regarding antibiotic choice it is wise to seek the
ing appendicectomy and cholecystectomy where no opinion of an infectious diseases clinician. For the
major break in technique was encountered. These majority of wounds a single dose of antibiotic is
wounds have a higher rate of SSI. indicated, but in the presence of significant contam
ination or in lengthy operations a supplementary
dose may be indicated. Prolonged prophylactic use
Contaminated
of antibiotics has not been proven to reduce the risk
Operations involving gross spillage of intestinal of SSI and is associated with an increased risk of
contents or where major breaks in sterile technique development of antibiotic‐resistant bacteria.
have occurred are described as contaminated.
Dirty or infected Intraoperative management

Wounds with signs of clinical infection such as
Skin preparation
neglected traumatic wounds or wounds in associa
tion with perforated viscera are described as dirty To minimise contamination of the wound from
wounds. skin flora, an antiseptic skin preparation is used.
6: Management of surgical wounds 47
A solution of chlorhexidine in alcohol is more open using a vacuum dressing to control the result
effective in reducing SSI than aqueous solutions. ing laparostomy. Patients are transferred to an
Care must be taken to prevent pooling of alcohol‐ intensive care unit for resuscitation, including vas
containing skin preparations especially when dia cular filling, correction of any metabolic or clotting
thermy is used to avoid ignition of the flammable abnormality and warming to normal temperature.
solution. Alcoholic solutions should not be used The patient is subsequently returned to the operat
around the eyes or in the external auditory canal to ing theatre in 24–48 hours for closure of the wound.
avoid corneal damage or the potential for the alco
hol to affect the inner ear.
Postoperative management
Choice of wound closure technique
General patient care
The method of wound management is finally
To support wound healing the patient’s general con
decided at the completion of the operation, taking
dition should be optimised. Adequate fluid resusci
into account the preoperative risk assessment, the
tation to maintain wound perfusion, ensuring
conduct of the surgery and the patient’s physiologi
oxygen saturation is above 95% if possible, avoid
cal state. The surgical choices are to manage the
ing hypothermia and providing nutritional support
wound open, to partially close the wound or, as in
will ensure the best conditions for wound healing.
most instances, to close all layers of the wound.
In a well patient with a clean or clean contaminated
Local wound care
wound, primary wound closure is recommended. This
is achieved by closure of any deeper layers of the The care of the wound will depend on the chosen
wound such as the fibrofacial layer of the abdomen method of wound healing.
with a strong, usually slowly absorbed, non‐irritant Wounds closed at the end of the operation with
monofilament suture. In thin patients where no the expectation of healing by primary intention
undermining of the wound edges has occurred, the require a protective supportive dry dressing which
subcutaneous layer does not require any suturing. The only needs attention for the first few days if there
skin edges are then opposed accurately, avoiding any are concerns about the possible onset of infection or
gaps using sutures or staples. Both techniques produce if there is soiling or exudation visible. Wounds with
comparable results with no significant difference in well‐opposed skin edges undergoing normal healing
SSI between continuous or interrupted suture tech should achieve re‐epithelialisation between the skin
niques. In general, low tension sutures are more con edges within 24–48 hours. While it is safe to allow
ducive to healing while excessive tension can produce showering once the wound is sealed, most patients
pressure injury to the wound edge. Retention sutures prefer a protective dressing over the wound to mini
in abdominal wall closure have not been found to pre mise the chances of abrasion from clothing or inad
vent wound dehiscence or evisceration or lessen SSI or vertent tension on the wound causing separation of
postoperative wound pain. the edges. For these reasons, dressings are usually
For wounds with significant contamination or in left intact for 5–7 days, after which the wound may
patients with major continuing risk factors for SSI, be left open. A number of waterproof dressing are
the surgeon may decide to close only the deeper lay available to allow normal showering during this
ers of the wound, leaving the superficial layers open healing phase. Closed wounds at greater risk of
to allow free drainage of any inflammatory exu healing problems may benefit from the use of nega
date. A subsequent wound management plan is tive pressure wound therapy. These dressing are
developed postoperatively based on assessment of designed to stay on for 5–7 days. The potential ben
the state and progress of the wound. If no signs of efits of these dressings are the removal of exudate,
infection appear to be developing, the edges of the reduction in lateral wound tension and a decreased
wound appear healthy and exudation is minimal, chance of seroma or haematoma formation. The use
delayed primary closure is usually performed. If the of these expensive dressing techniques is currently
wound is slow to progress and separation of the being investigated in randomised controlled trials.
edges occurs, the resulting unhealed wound may be Open surgical wounds require a dressing tech
suitable for split skin grafting. This is referred to as nique that controls wound discharge, minimises
healing by tertiary intention. bacterial contamination, provides a moist wound
In patients who are very unstable at the comple environment and is comfortable for the patient. For
tion of surgery, particularly with abdominal opera small wounds hydroscopic gels covered by a semi‐
tions, a decision may be made to leave the wound occlusive absorbent layer may be suitable. For
larger open wounds negative pressure wound ther of Surgical Wound Complications. Canadian
apy has revolutionised patient and wound care. Association of Wound Care, 2018. Available at www.
These devices are utilised until a healthy granulat woundscanada.ca
ing wound base is achieved, following which skin
grafting or vascularised flaps are contemplated to
provide permanent epithelial cover. MCQs
Wound packing and the frequent use of hypochlo
rite‐soaked dressings are becoming treatments of
the past as rapid advances in dressing technology
evolve. Chronic slow to heal wounds are best cared
for by wound care specialists who possess the skills 1 Regarding antibiotic wound prophylaxis:
and understanding necessary to select the most a broad‐spectrum antibiotics should be used
appropriate management plan for these difficult following wound closure until there are signs of
and distressing clinical situations. epithelial closure
b antibiotic prophylaxis must be used prior to
Wound follow‐up closure of all wounds
c antibiotic prophylaxis should be used when
All surgical wounds should be reviewed in 7–10 days
prosthetics are implanted at surgery
to ensure infection‐free healing is occurring. Any
d prophylactic antibiotics should be used for at
signs of infection should prompt action, with antibi
least 48 hours
otic therapy for mild cellulitis or wound drainage if
e antibiotic wound prophylaxis should include
there are signs of suppuration (pus formation). In
coverage of anaerobic organisms
small wounds drainage may be accomplished, using
an aseptic no‐touch technique, by gently opening the
2 Which of the following factors has not been proven
wound using artery forceps at the site of swelling.
to delay wound healing?
Any fluid drained should be sent for microbiological
a uncontrolled diabetes
testing to direct antibiotic therapy if indicated.
b malnutrition
SSI surveillance should extend for 30 days for
c corticosteroids
superficial incisional and deep incisional wounds;
d anxiety
90‐day follow‐up is recommended for surgery
e smoking
involving prostheses. Some deep SSIs may not be
clinically apparent for many months or even years
3 Wound infection is more common following:
following surgery, for example the newly recog
a the use of a continuous skin closure technique
nised slow‐growing mycobacterial infections fol
b primary closure of contaminated wounds
lowing surgery involving cardiopulmonary bypass.
c delayed closure of contaminated wounds
d removal of the sterile wound dressing in less than
5 days
Further reading
e the use of sterile saline rather than antiseptic
Harris CL, Kuhnke J, Haley J et al. Best Practice solutions for wound cleansing
Recommendations for the Prevention and Management
7 Nutrition and the surgical
patient
William R.G. Perry1 and Andrew G. Hill2
1
Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
2
University of Auckland and Middlemore Hospital, Auckland, New Zealand
malnutrition, response to stress and injury, and

Introduction nutritional interventions.
The last 10 years have been exciting times for sur-

geons. Along with advances in surgical techniques Nutrition
and perioperative care, there has been significant
improvement in understanding nutrition and the Nutritional requirements
nutritional management of surgical patients.
There are six components of adequate nutrition: pro-
Such advances in nutrition have developed in par-
tein, water, energy, electrolytes, minerals and vitamins
allel with a growing understanding of metabolic
(Table 7.1). The requirements for these different com-
responses to injury and sepsis. This field has been
ponents vary according to the patient and the clinical
energised by discoveries in molecular biology, includ-
condition. Daily energy requirements are approxi-
ing the role of proinflammatory and anti‐inflamma-
mately 25–30 kcal/kg. This energy is the result of the
tory cytokines as biological response modifiers, the
breakdown of carbohydrates, fats and proteins.
putative role of oxygen free radicals, and the identi-
Proteins are required for maintenance of normal cel-
fication of other mediators of the inflammatory
lular function and are an essential component of
response. Knowledge of metabolism and expertise in
dietary intake. Daily recommended intake is 0.8 g/kg.
nutrition are now fundamental for all surgeons.
Proteins themselves are made up of smaller
Nutrition features low in the body’s homeostatic
amino acid units held together by peptide bonds.
economy. Its priorities are oxygen delivery, regula-
Amino acids can be divided into essential and non‐
tion of acid–base balance and maintenance of fluid
essential, the latter so‐named because we are able to
compartments. Threats to oxygen delivery are dealt
synthesise them ourselves. Correspondingly, we rely
with almost instantaneously by changes in minute
on dietary intake of essential amino acids.
ventilatory volume, alterations of cardiac output,
Finally, several other elements are required for
and improved efficiency of oxygen uptake and
metabolism and growth. These include water‐solu-
extraction by tissues. Acid–base abnormalities take
ble vitamins (B and C), fat‐soluble vitamins (A, D, E
longer to adjust, with both acute buffering and
and K), and trace elements such as copper, iron,
chronic excretion mechanisms. Changes in extra-
selenium and zinc.
cellular and intracellular compartment volumes
occur even more slowly.
Body composition
The body’s adjustments to malnutrition are slower
still, because they are not immediately life‐threaten- The energy stores and body composition of an
ing. Nevertheless, these changes are profound and average 40‐year‐old man weighing 73 kg are shown
critical. Nutritional deprivation and inappropriate in Table 7.2. Of note, women have lower total body
response to the deprived state are a major cause of water, less muscle mass and higher total body fat.
morbidity and mortality in the surgical setting, par- Composition also varies by ethnicity.
ticularly in the context of sepsis and injury. Fat can be hydrolysed to free fatty acids and glyc-
This chapter explores this paradigm by review- erol, representing a high‐energy source producing
ing body composition, nutritional requirements, 9.4 kcal of energy per gram (Box 7.1). The body’s
49
Table 7.1 Nutrition requirements in 25–55 year olds.
Component Requirement in health Requirement after major surgery
Protein 1.0–1.5 g/kg 1.5–2.0 g/kg

Water 40 mL/kg Variable per losses
Energy 40 kcal/kg 40 kcal/kg
Electrolytes 75 mmol sodium Variable per losses
15 mmol potassium
Minerals 15 mEq calcium Variable per losses
40 mmol potassium
10 mEq magnesium
Vitamins B group, C, fat soluble Additional vitamins may benefit during surgical illness
<17 kg/m2 in males). Severe malnutrition can be

Table 7.2 Energy stores and body composition
defined as measured weight being greater than 20%
in a 40‐year‐old 73‐kg man.
less than ‘well’ weight. Approximately 5% of patients
Mass (kg) Available energy (kcal) coming to surgery are severely malnourished, and
malnutrition is present to varying degrees in up to
Water 42 0 50% of patients who have undergone surgery.
Fat 15 110 000 Studies of malnourished children, particularly in
Protein 12 25 000
the context of low‐ and middle‐income countries,
Glycogen 0.6 2 500
have recognised two broad syndromes of malnutri-
Minerals 3.4 0
tion that can be usefully transposed to the adult sur-
gical setting. The first is marasmus, due to inadequate
intake of an otherwise balanced diet (Table 7.3). In
Box 7.1 Energy availability the adult this is commonly termed protein–energy
malnutrition (PEM). Marasmus can result from
• Fat 9.3 kcal/g
anorexia, a decrease in appetite. However, depres-
• Glucose 4.1 kcal/g
• Protein 4.1 kcal/g
sion, medications, dementia and illness are more
common causes in hospitalised patients.
The second entity is kwashiorkor, which results
stores of carbohydrate are low and act as a rapid‐ from an inadequate as well as unbalanced diet con-
response provider of glucose, particularly in stress taining relatively more calories than protein. There
situations. Of the body protein, 45% is structural is characteristic fluid retention, which may mask
and not available for metabolic interchange, while the commonly seen and often rapid erosion of mus-
the remaining 55% is circulating proteins or con- cle and fat stores. In the adult patient, this is often
tained in cells. If this protein is lost it leads to loss seen with sepsis and after trauma.
of function, including muscle weakness and immune It also useful to know of two further subsets of
deficiency. The ratio of the fat‐free mass (total body malnutrition, cachexia and sarcopenia. Cachexia is
weight minus fat) to total body water (fat‐free body characterised by profound loss of adipose and
hydration) is remarkably constant in a healthy per- skeletal muscle mass with associated haematologi-
son, but varies markedly in the unwell patient. cal derangement and deconditioning. It usually
results from an interplay of altered metabolism
and inflammation. Common causes include meta-
Malnutrition bolic disease, cancer, acquired immunodeficiency
syndrome (AIDS) or end‐stage organ disease states.
Malnutrition is the inability to match both meta- Sarcopenia is the loss of muscle mass and quality
bolic and nutrient requirements. The European and manifests as frailty. It is associated with
Society for Clinical Nutrition and Metabolism decreased strength, and results from reductions in
(ESPEN) has defined it as either (i) BMI below 18.5 androgenic hormones, increasing resistance to
kg/m2 or (ii) weight loss over 10% (or 5% over 3 insulin, decreased exercise and decreased protein
months) and reduced BMI (<20 kg/m2 if <70 years intake that is seen with ageing.
old, <22 kg/m2 if >70 years old) or a low fat‐ Diseases also play an important role in malnutri-
free mass index (FFMI, <15 kg/m2 in females and tion syndromes. Gastrointestinal disease can produce
7: Nutrition and the surgical patient 51
Table 7.3 Comparisons between marasmus and kwashiorkor
Marasmus Kwashiorkor
Nutritional defect Impaired delivery Impaired utilisation

Protein catabolism Compensated Uncompensated
Aetiology No food Sepsis
No appetite Major trauma
Gastrointestinal dysfunction Burns
Metabolic rate Normal or reduced Increased
Prognosis if untreated Months Weeks
Principles of treatment Replenish with standard nutrition Resuscitate and support
Use simplest available route Control sepsis
Treat underlying illnesses, if any Provide non‐standard nutritional regimens
Clinical course Straightforward Complicated
obstruction, malabsorption and fistulas resulting in marasmus the body undergoes an important
gastrointestinal dysfunction. Inflammatory media- change, over several days, to using ketone bodies
tors associated with the inflammatory phlegmon (keto‐adaptation) from fat as brain fuel. This adap-
may secondarily lead to PEM and worsen fluid tation preserves muscle protein.
and electrolyte disturbances. AIDS leads to severe In sepsis and trauma, however, this does not
cachexia, similar to that seen in cancer. This is prob- occur. Surgery, injury or infection induces a sys-
ably mediated by cytokines such as tumour necrosis temic inflammatory response – a complex inter-
factor (TNF)‐α and is complicated by chronic infec- play of proinflammatory and anti‐inflammatory
tion and malignancies. In cancer there is a rise in rest- responses – and modification of immunological
ing energy expenditure and the tumour avidly retains and non‐immunological pathways. The metabolic
nitrogen as well as operating at a glucose‐wasteful, response to systemic inflammation is shown in
high rate of anaerobic metabolism. Unlike the situa- Figure 7.1. Glycogen, fat and protein are catabo-
tion in experimental animal models, these tumour lised to increase glucose, free fatty acids and amino
effects are unlikely to explain the degree of cachexia acids in the circulation that are integral to the
often seen in humans. Cancer‐induced anorexia and immune response and phases of healing. As a result,
host cytokine production are probably involved. there is a decrease of these substrates in the periph-
eries for maintenance of protein with a resultant
loss in muscle mass, which ultimately impacts on
Response to stress and injury functional recovery.
With severe sepsis and in burns, this protein
In starvation, glycogen is initially broken down to catabolism is even more marked and energy
produce glucose in order to maintain brain func- expenditure massively increases, fuelled by intense
tion. However, glycogen is rapidly exhausted and in free fatty acid oxidation. All the while, there is a
Systemic inflammatory response
Increase glucose, FFA, AA Decrease glucose, FFA, AA

in circulation in peripheries for maintenance of protein
Rx nutrition
Decrease muscles mass and exercise
Healing Immune response
Immunonutrition
Decrease functional recovery
Fig. 7.1 Metabolic response to systemic inflammation. AA, amino acid; FFA, free fatty acid.
blunted systemic inflammatory response which can

Box 7.2 Markers for nutritional
lead to hypothermia, leucopenia and impaired heal-
assessment
ing amongst other sequelae.
The body’s response to surgery is now known to • Anthropometric measures: skinfold thickness
last well beyond the initial postoperative period. (biceps, triceps, subscapular), BMI
Within a few minutes of beginning an operation the • Biochemical measures: albumin, lymphocyte count,
level of counter‐regulatory hormones (cortisol, gluca- skin recall antigens
gon and catecholamines) rises. In uncomplicated sur- • Clinical history
gery these act only to initiate protein catabolism, as • Dietary history
the endocrine response is relatively short‐lived (lasting
24–48 hours). However, protein catabolism continues
for up to 1 month after major surgery as a result of much remains. Most screening tools therefore
proinflammatory cytokines such as TNF‐α, interleu- address four main principles.
kin (IL)‐1, IL‐6 and IL‐8. These probably act locally, 1 What is the patient’s current condition? For
at the site of injury, and indirectly (via the blood- example, what is their BMI?
stream and in the central nervous system). Imbalances 2 Is their condition stable? Do they have more than
between proinflammatory and anti‐inflammatory 5% involuntary weight loss over 3 months?
cytokines also probably play a role in anorexia, 3 Will the condition get worse? Have they recently
pyrexia, fatigue and fat catabolism. reduced intake for example?
4 Will the disease process accelerate nutritional
Consequences of injury and malnutrition deterioration?
Nutritional assessment begins with a careful clini-
Malnutrition is associated with increased postop- cal evaluation. Important features of the history are
erative complications, mortality, increased length of weight loss greater than 5% during the past 3
stay and decreased quality of life. It is complicated months and a change in exercise tolerance. Physical
by immune incompetence and decreased wound examination may reveal non‐healing wounds,
healing ability. Protein–energy metabolism may oedema and fistulas.
be accompanied by physiological changes such as Body composition is assessed by simple clinical
poor muscle function, manifest as physical weak- tests and a standard blood test. Loss of body fat is
ness and poor respiratory muscle function. Such often apparent from observations of the patient but
changes increase postoperative complications such is also assessed by palpating the triceps’ and biceps’
as pneumonia and prolong length of stay. skinfolds. If the dermis can be felt between finger
Furthermore, oncological outcomes can also be and thumb, then it is likely that the body mass is
compromised by poor perioperative nutrition. composed of less than 10% fat.
Fatigue is a common concomitant of surgical ill- Protein stores are assessed by observation and
ness and is characterised by prolonged mental and palpation of the temporalis, deltoids, suprascapular
physical exhaustion. After surgery it is most pro- and infrascapular muscles, the bellies of biceps and
nounced at 1 week, and slowly improves for up to 3 triceps and the interossei of the hands. If the ten-
months. It is worse in the elderly, in patients who were dons are palpable or the bony shoulder girdle is
tired prior to surgery and in patients with cancer. sharply outlined (tendon–bone test), then the
patient is likely to have lost more than 30% of total
body protein stores.
Nutritional assessment Plasma albumin levels are of assistance in deter-
mining the type of PEM. In kwashiorkor, the albumin
Some 30% of all patients presenting to hospital are may be low, reflecting the expansion of the extracel-
malnourished. It is thus important to screen patients lular fluid space, and this may manifest clinically as
to help predict outcomes and enable nutritional pitting oedema. It is a good prognostic indicator,
intervention. However, there is only one prospec- with values less than 30 g/L associated with poorer
tively validated scoring system, the Nutritional surgical outcomes. However, it is a poor nutritional
Risk Screening (NRS‐2002) (Figure 7.2), and no marker, since those suffering from starvation may in
single clinical or laboratory test defines nutritional fact have a normal serum albumin. Furthermore, it is
status (Box 7.2). a negative acute‐phase protein. As such, albumin val-
The aim of nutritional assessment is to define ues must be interpreted with caution.
how much the patient has lost from his or her body Assessment of physiological function is of vital
stores of protein and fat and, as a corollary, how importance because weight loss without evidence
Part A: Initial screening

1. Is BMI <20.5?
2. Has patient lost weight within last 3 months?
3. Has patient had a reduced dietary intake in the last week?
4. Is the patient severely ill? (e.g. in intensive care)
If yes to any of these questions, proceed to Part B. If no, rescreen weekly.
Part B: Final screening

Impaired nutritional status Severity of disease (= increase requirements)
Absent Normal nutritional status Absent Normal nutritional requirements
Score 0 Score 0
Mild Wt loss >5% in 3 mths or food intake Mild Hip fracture; Chronic patients, in
Score 1 below 50-75% of normal requirement Score 1 particular with acute complications:
in preceding week cirrhosis, COPD
Chronic hemodialysis, diabetes,
oncology
Moderate Wt loss >5% in 2 mths or BMI 18.5– Moderate Major abdominal surgery; Stroke
Score 2 20.5 & impaired general condition or Score 2 Severe pneumonia, hematologic
food intake 25-60% of normal Malignancy
requirement in preceding week
Severe Wt loss >5% in 1 mth (>15% in 3 Severe Head injury; Bone marrow
Score 3 mths) or BMI <18.5 & impaired Score 3 Transplantation
general condition or food intake Intensive care
0-25% of normal requirement patients (APACHE410).
in preceding week
Score + Score = TOTAL SCORE
Age If age >70 add 1 to give “Age-adjusted total score”
Score 3+: the patient is nutritionally at-risk and a nutritional care plan is initiated.
Score <3: weekly rescreening of the patient. If the patient e.g. is scheduled for a major operation, a
preventive nutritional care plan is considered to avoid the associated risk status.
Diagnoses shown in italics are based on the prototypes for severity of disease:
Score= 1: a patient with chronic disease, admitted to hospital due to complications. The patient is weak
but out of bed regularly. Protein requirement is increased, but can be covered by oral diet or supplements
in most cases.
Score= 2: a patient confined to bed due to illness, e.g. following major abdominal surgery. Protein
requirement is substantially increased, but can be covered, although artificial feeding is required in many
cases.
Score= 3: a patient in intensive care with assisted ventilation etc. Protein requirement is increased and
cannot be covered even by artificial feeding. Protein breakdown and nitrogen loss can be significantly
attenuated.
Fig. 7.2 Nutritional Risk Screening (NRS 2002). Source: Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN
guidelines for nutrition screening. Clin Nutr 2003;22:415–21. Reproduced with permission of Elsevier.
of physiological abnormality is probably of limited major surgery or trauma in the preceding week and
consequence. Function is observed while perform- where there is evidence of sepsis or ongoing inflam-
ing a physical examination and then by watching mation, such as inflammatory bowel disease.
the patient’s activity on the ward. Grip strength is Determining the intensity and type of malnutrition
assessed, and respiratory muscle strength is assessed is of great importance in setting nutritional goals.
by asking the patient to blow hard holding a strip When PEM is severe and affects physiological func-
of paper 10 cm from the lips. Severe impairment is tion, postoperative complications are more common
present when the paper fails to move. and postoperative stay is prolonged. The identifica-
Metabolic stress will be revealed by history and tion of metabolic stress is also important: because
examination. It is present if the patient has had the extracellular water is expanded, the response to
standard nutritional intervention is impaired and the

Box 7.3 Principles of nutritional
type of malnutrition is predictable.
intervention
• Preoperative nutrition is indicated in severely

Perioperative nutrition malnourished patients.
• Postoperative early tube feeding within 24 hours
Patients often face prolonged preoperative fasting should be initiated in those where early oral
and oral restriction postoperatively. This paradigm nutrition cannot be started and in whom oral
has changed with greater understanding of anaes- intake will be inadequate for more than 7 days.
thetic risk profiles and postoperative metabolic • Postoperative total parenteral nutrition is provided
requirements respectively. Patients are now encour- if a normal intake has not been established within
aged to maintain solid intake up to 6 hours, and 5–7 days for a depleted patient and 7–10 days for
clear fluids up to 2 hours, preoperatively. Some sur- a normal patient.
geons encourage carbohydrate drinks in the preop- • When possible, enteral nutrition is preferred over
erative period, although the evidence is mixed. It parenteral nutrition.
certainly does not increase the risk of aspiration,
and may reduce anxiety and decrease length of stay
for those undergoing major surgery. Box 7.4 Indications for nutritional
Postoperatively, early oral nutrition is encour- intervention in surgical patients
aged, and is a key component in enhanced recovery
after surgery (ERAS) programs. ERAS involves a Indications for preoperative nutrition
combination of interventions that aim to minimise • Severe malnutrition with physiological impairment
stress and accelerate return to function. It includes Indications for total parenteral nutrition
preoperative and postoperative nutrition and fluid • Gut is obstructed
balance guidelines, perhaps the most important of • Gut is short
which is early implementation of postoperative oral • Gut is fistulated
feeding rather than the once traditional ‘gut rest’. It • Gut is inflamed
was initially developed for colorectal surgery but • Gut cannot cope
has now been promoted across several specialties.
Indications for enteral nutrition
In fact, its nutritional principles have been adopted
• Malnutrition with a functioning gut
in non‐operative patients as well. The guidelines for
• Postoperative feeding
acute pancreatitis published by the International
Association of Pancreatology (IAP) and the
American Pancreatic Association (APA) include
importance in laboratory models. Enteral nutrition
early oral feeding for mild pancreatitis and consid-
is administered by mouth if possible (as high‐energy
eration of tube feeding within 48 hours in severe
nutritional supplements), but may also be delivered
pancreatitis, a move away from what again used to
by a fine‐bore feeding tube introduced under fluor-
be the more traditional nil‐by‐mouth approach.
oscopic control or using an endoscope. Fine tubes
can also be placed into the jejunum at surgery and
Indications for nutritional intervention
feeding can begin in the recovery room after the
The principles of nutritional intervention are sum- operation is complete. If prolonged enteral feeding
marised in Box 7.3. Nutritional intervention is indi- is anticipated, a gastrostomy should be created,
cated prior to surgery only in severely malnourished usually via the percutaneous endoscopic route.
patients with physiological impairment. Nutritional
support is required in patients who cannot eat, in Intravenous nutrition
whom intake is insufficient for their needs, in whom
Intravenous nutrition or total parenteral nutrition
the gastrointestinal tract cannot be used and in
(TPN) is useful if the gut is obstructed, too short,
those with accelerated losses (Box 7.4).
fistulated, inflamed or simply cannot cope, such as
in prolonged postoperative ileus. TPN formulations
Enteral nutrition
generally comprise 60–70% dextrose and 10–20%
In circumstances where the gut is functional, enteral amino acids, with lipid emulsion, vitamins and min-
nutrition should be preferentially used. Enteral erals added as required. It is administered by a dedi-
nutrition may be important in maintaining gut cated central venous catheter inserted under sterile
barrier function, demonstrated to be of critical
conditions.
Approximately 50 kcal/kg body weight per day It should be given for approximately 7 days preop-
and 0.3 g/kg of nitrogen as amino acids per day is eratively and postoperatively.
required to achieve gain in body protein. Use of
nutritional intervention must be preceded by cor- Other adjuncts
rection of anaemia, hypoalbuminaemia, fluid and
Epidural anaesthesia blocks much of the early stress
electrolyte abnormalities, and deficits in trace met-
response to surgery and this has been postulated to
als. Vitamins must be dealt with by appropriate
be of critical importance in slowing protein loss.
infusions so that administered nutrients will be
What may be of more importance is the mobility
used efficiently.
that epidural anaesthesia permits the surgical
TPN is not without complications. Central venous
patient in the immediate postoperative period and
catheter infection is potentially life‐threatening and
the ability of the epidural block to limit postopera-
therefore care must be meticulous. Implementation
tive ileus, at least partially due to an opiate‐sparing
of the Centers for Disease Control’s Checklist for
ability.
Prevention of Central Line Associated Blood
Non‐steroidal anti‐inflammatory drugs (NSAIDs)
Stream Infections (https://www.cdc.gov/hai/pdfs/bsi/
may be important in preventing arachidonic acid‐
checklist‐for‐CLABSI.pdf) has seen a significant
mediated tissue damage, as may nitric oxide inhibi-
reduction in infection rates worldwide. TPN has
tion and antioxidants in limiting free oxygen radical
been associated with increased gastrointestinal
damage. These await further evaluation in clinically
bacterial translocation, a heightened proinflamma-
relevant models.
tory state and increased pulmonary dysfunction.
Minimal access surgical interventions have led, in
Overfeeding in particular can lead to respiration dif-
many cases, to earlier recovery from surgery and
ficulties, and excess carbohydrate or fat can lead to
faster return to work. When these techniques are
fatty liver. Excess protein replacement can lead to
combined with other modulators, the improve-
elevations in blood urea nitrogen. Long‐term TPN
ments in postoperative outcome are likely to be
users can also suffer from osteoporosis, although the
quite profound.
aetiology is unclear.
Immunonutrition
Conclusion
Immunonutrition is the supplementation of nutri-
ents that are thought to impact both immune Short‐term preoperative nutritional intervention in
and inflammatory response to injury. These include severely compromised patients decreases postoper-
arginine, omega‐3 fatty acids and glutamine ative complications. The effect is not nearly as
(Table 7.4). Studies investigating the utility of apparent in patients with mild to moderate malnu-
immunonutrition have varied in quality and indeed trition. Postoperative nutritional support is one of
outcome. Consensus is still building, but it is likely the most important developments in modern sur-
that it may have a role in severely malnourished gery and has allowed surgeons much greater leeway
patients with severe trauma, sepsis, acute respira- in the management of surgical complications such
tory distress syndrome and head and neck cancers. as fistulas and bowel obstruction.
Table 7.4 Components of immunonutrition.
Biological function Outcome
Arginine Stimulates immune cells, precursor May decrease infection, reduce

Conditional amino acid to nitric oxide which may improve length of stay
microvascular perfusion
Omega‐3 fatty acids Maintain cell membranes and Some evidence of decreased
Polyunsaturated fatty acids, e.g. modulate inflammatory response mortality, clinically safe
docosahexaenoic acid (DHA) and
eicosapentaenoic acid (EPA)
Glutamine Antioxidant, precursor to May decrease infection, reduce
Conditional amino acid, 70% of glutathione providing energy for length of stay, improve quality of
amino acid mobilised during enterocytes, component of protein life, improve nitrogen balance,
stress response synthesis improve sugar control
3 The average requirement for intravenous nutrition

Further reading per day is:
a 20 kcal/kg body weight
Gustafsson U, Scott M, Hubner M et al. Guidelines for
b 30 kcal/kg body weight
perioperative care in elective colorectal surgery:
enhanced recovery after surgery (ERAS) society recom- c 40 kcal/kg body weight
mendations: 2018. World J Surg 2019;43:659–95. d 50 kcal/kg body weight
Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN e 60 kcal/kg body weight
guidelines for nutrition screening. Clin Nutr 2003;22:
415–21. 4 What percentage of patients being admitted to
Weimann A, Brago M, Carli F et al. ESPEN guideline: clini- hospital are malnourished?
cal nutrition in surgery. Clin Nutr 2017;36:623–50. a 10%
b 15%
MCQs c 30%
d 50%
Select the single correct answer to each question. The e 60%
at the end of the book. 5 Which of the following is not true?
a perioperative nutrition is only indicated in
1 Marasmus is characterised by the following
severely malnourished patients
characteristics except:
b postoperative early tube feeding within
a inadequate intake of an otherwise balanced
24 hours should be initiated in those where
diet
early oral nutrition cannot be started and in
b cachexia in the adult
whom oral intake will be inadequate for more
c fluid retention
than 7 days
d decreased metabolic rate
c postoperative total parenteral nutrition is
e easy correction with standard nutrition
provided if a normal intake has not been
established within 5–7 days for a depleted
2 Nutritional markers include the following except:
patient and 7–10 days for a normal patient
a skinfold thickness
d when possible, enteral nutrition is preferred over
b mid‐arm muscle circumference
parenteral nutrition
c total leucocyte count
d serum albumin
e skin recall antigens
8 Care of the critically ill patient
Jeffrey J. Presneill1,2, Christopher MacIsaac2
and John F. Cade1,2
1
University of Melbourne, Melbourne, Victoria, Australia
2
Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
A wide variety of comorbidities may adversely

Introduction to critical illness influence the prognosis for recovery following
critical illness, including ischaemic heart disease,

Intensive care for complex and potentially life‐
diabetes, peripheral vascular disease, severe chronic
threatening critical illness is currently provided to
obstructive airways disease or malignancy. In the
about 150 000 patients annually across Australia
absence of these comorbidities, selected patients of
and New Zealand. In Australia, at least 1.7% of
advanced age may benefit from short‐term ICU
acute hospital care episodes involved time in an
admission. Reliable prediction of patient outcome
intensive care unit (ICU), with the average ICU
would greatly assist patient selection, clinical man-
admission almost 4 days in duration, at an average
agement and resource allocation. Several regression
daily cost approaching A$5000.
model‐based systems for critical illness mortality
The concept of ICUs developed over 60 years ago,
prediction are in common use internationally. Such
initially for prolonged mechanical ventilation sup-
models define average effects rather than individual
port. Expanding demand for critical care services has
variation, making them suitable for group compari-
led to there being over 200 ICUs in Australia and
sons but not as arbiters of individual patient care.
New Zealand, with many classified as level 3 or ter-
tiary, meaning hospital facilities capable of support-
ing patients with complex multisystem organ Causes of critical illness
dysfunction for an indefinite period using methods
such as mechanical ventilation, extracorporeal renal The chief categories of causes of critical illness and
support services and invasive cardiovascular moni- thus admission to ICU are shown in Figure 8.1.
toring. Such intensive care has permitted many Severe infection remains the most common and
patients to survive hitherto fatal illness or injury, with concerning problem in the care of seriously ill
the interesting consequence that complex pathophys- patients in hospitals worldwide. The rapid diagno-
iological responses are now seen which could never sis of sepsis is an urgent medical priority, as early
have originally been adaptive, which could be help- identification and appropriate immediate manage-
ful, harmful or neutral and which in turn have led to ment in the initial hours after development of sepsis
new therapeutic opportunities and challenges. is likely to improve patient outcomes. Severe infec-
Overall slightly more than 90% of patients sur- tion provides an important link between either
vive admission to ICU in Australia and New underlying or complicating illness and serious con-
Zealand (Figure 8.1). However, an adverse post‐ ditions such as circulatory, respiratory and other
ICU syndrome of prolonged physical, cognitive and organ dysfunction. Some common definitions of
mental health dysfunction is well described interna- infection and related phenomena such as sepsis
tionally in some survivors of critical illness and and septic shock are shown in Box 8.1. Clinically
their caregivers. A substantial proportion of these suspected sepsis occurs in approximately 1% of
declines may be explained by patient age and Australian hospital admissions, 10% of ICU admis-
comorbidities prior to ICU admission rather than sions, and has a hospital mortality ranging from less
the episode of critical illness itself, and recent than 5% (in the absence of comorbidities and older
Australian data suggest ICU survivors experience a age) to 20%. Septic shock may have a mortality of
quality of life they find acceptable. approximately 40%, despite early antimicrobial
57
Circulatory Respiratory Severe Organ Metabolic

dysfunction dysfunction Trauma Surgery dysfunction dysfunction
infection
ICU
Resuscitation Specific
Diagnosis
therapy (if any)
10–20%
≥75% ≤5%
Persistent
Early cure Early death
critical illness
Isolated ARDS MODS

Low mortality Variable mortality
Fig. 8.1 Pathways of critical illness.
therapy and intensive life support; however, delayed necessarily involve microbial infection. The
recognition of sepsis and administration of relevant constellation of clinical, haematological, and

antibiotics may substantially worsen patient out- biochemical signs typically found in the presence
come. Survivors of severe sepsis commonly exhibit a of infection can often be observed at least tran-
complex post‐sepsis immune dysfunction with both siently in the absence of any identifiable infection,
innate immune dysregulation and adaptive immune as with pancreatitis, trauma, burns, rhabdomyoly-
suppression featuring simultaneous inflammatory sis, necrotic tissue and cardiopulmonary bypass.
and anti‐inflammatory responses that may persist Patients who are critically ill due to suspected sep-
to hospital discharge after clinical recovery. sis or septic shock should receive empirical antimi-
An expanding global problem is the continually crobial therapy as soon as possible, ideally once
emerging antibiotic resistance of microorganisms, cultures of blood and urine samples have been
which challenges the success of the complex and obtained. Attempts are ongoing to develop spe-
invasive procedures that characterise modern hospi- cific and sensitive diagnostic tests for sepsis using
tal practice. The most commonly isolated organisms biomarkers such as procalcitonin or numerous
are Staphylococcus aureus, Staphylococcus epider- others that may improve on the current non‐spe-
midis, Streptococcus pneumoniae, Streptococcus cific clinical signs and long‐standing laboratory
pyogenes, various enterococci, Gram‐negative tools (e.g. white cell count, C‐reactive protein)
bacilli and Candida spp. When sepsis is suspected used to diagnose infection.
but the site remains unknown despite an appropri- Over the last 10 years, multiple randomised trials
ately thorough clinical investigation, potential have investigated therapeutic approaches used in
sources include lungs, urinary tract, abdomen, skin the clinical support of patients with sepsis and sep-
or soft tissue, musculoskeletal system, central nerv- tic shock. An initial report of improved survival
ous system and intravascular devices. with a protocol‐based approach to sepsis manage-
The bodily responses to severe infection may be ment involving a ‘bundle’ of specified interventions
indistinguishable from those due to non‐infective termed early goal‐directed therapy (EGDT) was not
inflammation or indeed to severe injury itself. The confirmed by a meta‐analysis of individual patient
systemic response to injury in general is referred data from three subsequent large multicentre trials
to as the systemic inflammatory response syn- testing the EGDT approach.
drome (SIRS; Table 8.1). The definition of SIRS For those patients with sepsis who remain hypo-
describes a widespread inflammatory response to tensive despite adequate fluid resuscitation, two
a variety of clinical insults, not all of which common choices of vasopressor agents used by
8: Care of the critically ill patient 59
Box 8.1 Definitions relevant to the evaluation of sepsis
Infection
A microbial phenomenon characterised by an inflammatory response to the presence of microorganisms or the
invasion of normally sterile host tissue by those organisms.
Bacteraemia
The presence of viable bacteria in the blood. Similarly, for other classes of microorganisms including fungi, viruses,
parasites and protozoa.
Systemic inflammatory response syndrome (SIRS)

Consists of two or more of the following:
• temperature >38°C or <36°C
• heart rate >90 beats/min
• respiratory rate >20 breaths/min or Paco2 <32 mmHg
• leucocyte count >12 × 109/L, <4 × 109/L, or >10% immature (band) forms.
Sepsis
Sepsis is life‐threatening organ dysfunction caused by a dysregulated host response to infection. It is a syndrome of
physiological, pathological and biochemical abnormalities induced by clinically diagnosed infection, where the
absence of positive cultures does not exclude the diagnosis. Sepsis is a syndrome without, at present, a validated
standard diagnostic test. Any unexplained organ dysfunction should thus raise the possibility of underlying
infection. The clinical and biological phenotype of sepsis can be modified by pre‐existing acute illness, long‐standing
comorbidities, medication and interventions. Specific infections may result in local organ dysfunction without
generating a dysregulated systemic host response.
For clinical operationalisation, organ dysfunction can be represented by an increase in the sequential (sepsis‐
related) organ failure assessment (SOFA) score of 2 points or more.
SOFA score
The score summarises (range 0–24) organ system abnormalities, and accounts for clinical interventions. Laboratory
variables, namely Pao2, platelet count, creatinine and bilirubin, are needed for full completion. Organ dysfunction
can be identified as an acute change in total SOFA score ≥2 points consequent to the infection. The baseline SOFA
score can be assumed to be zero in patients not known to have pre‐existing organ dysfunction.
Septic shock
Sepsis with persistent hypotension requiring vasopressors to maintain mean arterial blood pressure ≥65 mmHg and
with a serum lactate level >2 mmol/L despite adequate volume resuscitation. Adequate volume resuscitation remains
poorly defined. Many studies have specified an intravenous infusion of isotonic fluid, colloid or blood products to
restore the effective circulating blood volume. Other studies nominate a volume of 500 mL. Patients who are
receiving inotropic or vasopressor agents may not be hypotensive at the time that perfusion abnormalities are
measured. Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are
sufficiently profound to substantially increase mortality.
These designations are based on 2016 international definitions that have deleted the previous term ‘severe
sepsis’, meaning sepsis complicated by organ dysfunction (Singer et al. 2016). However, multiple older definitions
and terminologies remain in widespread clinical use, including the systemic inflammatory response syndrome,
severe sepsis, septic shock and various definitions of organ dysfunction/failure (Abraham et al. 2000; Kaukonen
et al. 2014).
Abraham E, Matthay MA, Dinarello CA et al. Consensus conference definitions for sepsis, septic shock, acute lung injury, and acute
respiratory distress syndrome: time for a reevaluation. Crit Care Med 2000;28:232–5.
Kaukonen KM, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe sepsis and septic shock among critically ill
patients in Australia and New Zealand, 2000–2012. JAMA 2014;311:1308–16.
Singer M, Deutschman CS, Seymour CW et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis‐3).
JAMA 2016;315:801–10.
intravenous infusion to elevate arterial blood pres- the use of 0.9% sodium chloride with its supra-
sure are noradrenaline and vasopressin, which have physiological chloride content has been associated
similar efficacy and toxicity. Beyond appropriate with the development of metabolic acidosis and
antibiotics, fluid and vasopressor resuscitation and also possibly acute kidney injury. In specific clinical
other critical care support, the role of adjunctive circumstances (e.g. raised intracranial pressure)
glucocorticoids in septic shock has been debated various hypertonic saline crystalloid solutions (e.g.
for several decades. In a recent large multicentre 3%) are used without strong clinical evidence of
randomised trial, hydrocortisone by infusion at 200 improved patient‐centred outcomes. Two recent
mg/day did not influence the risk of death at 90 large open label trials have reported a small advan-
days (which was the trial primary outcome) overall tage for balanced salt solutions (lactated Ringer’s
or in six pre‐specified subgroups. Faster resolution solution or PlasmaLyte A) compared with normal
of shock, from a median of 4 to 3 days, was noted saline with respect to renal function in hospitalised
but this may have been a chance observation. In a non‐critically ill patients, and also in critically ill
separate multicentre trial, the addition of fludro- patients where balanced crystalloid use was associ-
cortisone to hydrocortisone in severe septic shock ated with fewer occurrences of a composite adverse
was associated with some decrease in the risk of outcome (death from any cause, new renal replace-
death at 90 days from 49% to 43%, with a relative ment therapy, or persistent renal dysfunction).
risk of death in the hydrocortisone‐plus‐fludrocor- The prototypical colloid is human albumin solu-
tisone group of 0.88 (95% confidence interval, tion (e.g. 4% albumin in saline). Associated with
0.78–0.99). It remains to be determined if these the elevated cost and potentially limited interna-
contrasting trial results will change clinical practice tional availability of albumin solutions, several
with respect to adjunctive corticosteroid use in varieties of semi‐synthetic colloids were developed,
severe infection. comprising most commonly a form of hydroxyethyl
starch (HES), or succinylated gelatin, urea‐linked
gelatin–polygeline preparations and, least com-
Resuscitation monly, a dextran solution. While use of saline 0.9%
compared with albumin 4% in saline 0.9% in a
There is a potential but unproven role for limited large randomised trial resulted in equivalent patient
pre‐hospital fluid administration with permissive outcomes from critical illness, the overall ratio of
hypotension in adult trauma patients with haemor- the volume of albumin 4% to the volume of saline
rhagic shock during rapid transport to a suitable 0.9% administered was approximately 1 : 1.4 to
surgical facility for definitive haemostasis. In most achieve equivalent hemodynamic resuscitation end
other circumstances, conventional resuscitation points, such as mean arterial pressure or heart rate.
aims to be prompt and complete, with restoration Potential disadvantages of semi‐synthetic colloids
and maintenance of an adequate circulating blood compared to crystalloids have been reported. Use of
volume (that is, treatment of hypovolaemia). This is 6% HES as compared with saline in ICU patients
a fundamental requirement in all seriously ill was associated with increased need for renal
patients. Without adequate blood volume expan- replacement therapy, while in ICU patients with
sion, inotropes and other therapies are less likely to severe sepsis HES was associated with increased
be effective and organ function is likely to be com- mortality compared with the use of the balanced
promised. There is no universal ideal resuscitation crystalloid Ringer’s acetate.
fluid, although it is reasonable that replacement of The volume of acute fluid resuscitation required
losses should usually reflect the major deficit caused in critically ill patients may be a substantial number
by the underlying disease process. Non‐blood of litres. In addition to obvious losses and to antici-
resuscitation fluids are broadly categorised into pated third‐space needs, there is often extra volume
crystalloids and colloids. Crystalloids are further required due to vasodilatation, capillary leak and
described as ‘balanced’ if their chemical composi- blood flow maldistribution. Fluid resuscitation is
tion, especially their chloride content, approxi- complete if blood flow is restored (that is, the
mates extracellular fluid (e.g. Hartmann’s, Ringer’s haemodynamic goal) or if cardiac filling pressures
and PlasmaLyte solutions). In global clinical prac- are optimised, whichever is first. If a satisfactory
tice, the most commonly used crystalloid has been haemodynamic goal has not been achieved despite
the isotonic but ‘unbalanced’ 0.9% sodium chlo- suitable cardiac filling pressures and thus repair of
ride (so‐called normal saline), with 200 million hypovolaemia, inotrope therapy is required if myo-
litres per year administered in the USA. However, cardial contractility is impaired and/or vasopressor
therapy is required if blood pressure is inadequate organ systems: lungs, blood, liver, kidneys, brain
(e.g. in states of low systemic vascular resistance and circulation. With organ system dysfunction val-
due to vasodilatation). In hyperdynamic vasodi- ues from 0 (normal) to 4 (high degree of dysfunc-
lated septic shock, hypotension has been treated tion) based on the worst physiological disturbance
for many years by infusion of agents from one or in each 24 hours of a patient’s admission, the total
both of two major classes of vasopressors: (i) the SOFA score ranges from 0 to 24. Emphasis has
sympathomimetic amines/catecholamines such as shifted in the latest international sepsis and septic
noradrenaline or (ii) vasopressin or its longer‐act- shock definitions from SIRS to quantification of
ing analogue terlipressin. Very recently, a third class organ dysfunction using the SOFA score.
of natural vasopressor, angiotensin II, has emerged There are numerous other scores measuring the
in preliminary clinical trials after difficulty in its severity of illness, trauma or organ dysfunction that
manufacture were eventually solved. While adrena- may be used in the study of critical illness or to
line is the inotrope of choice specifically for ana- benchmark ICU performance. Among those more
phylactic shock, other agents may be used in shock commonly encountered are two versions of the
due to myocardial impairment, such as dopamine, Acute Physiology and Chronic Health Evaluation
or dobutamine often with low‐dose noradrenaline, score (e.g. APACHE II and III), the related Simplified
with such choices guided by clinical practice rather Acute Physiology Score (e.g. SAPS II) and more
than randomised evidence. recently the Australian and New Zealand Risk of
Death (ANZROD) model. As already mentioned,
all these regression‐based outcome prediction mod-
Organ dysfunction and severity of illness els return ‘population average’ estimates that do
not substitute for informed clinical experience in
Functional assessment of organ damage emphasises the proper management of individual patients.
a continuum of progressively worsening organ dys- The current overall mortality of all patients
function rather than an arbitrary dichotomy admitted to ICU in Australia and New Zealand is
between normality and organ failure. Thus, the 8–9%. While development of any substantial organ
older term ‘multiple organ failure’ is often replaced dysfunction, especially if multiple organ systems
by the broader term multiple organ dysfunction are involved (MODS), may increase the probability
syndrome (MODS). Except for the acute respira- of ICU or hospital mortality, the incidence of
tory distress syndrome (ARDS), which is the pul- MODS varies greatly with the patient group under
monary manifestation of MODS and which has consideration. In uncomplicated surgery, it is rare.
precise (though still arbitrary) definitions set by In serious and complicated surgical conditions,
international consensus, MODS has no universally such as trauma, haemorrhage or shock, it may
agreed set of definitions. These definitional difficul- occur in 20%. In uncontrolled sepsis, it may be sub-
ties arise primarily because of incomplete under- stantially higher. For patients with organ dysfunc-
standing of the complex interaction between tion, the time to recovery has been arbitrarily
inflammatory, genetic and potentially other influ- categorised as uncomplicated (<4 days), intermedi-
ences underlying the development of MODS, which ate (4–14 days) or complicated (>14 days).
may be observed following a wide range of human The pathogenesis of MODS remains unclear, and
injury, ranging from pancreatitis to severe trauma several models have been proposed, such as exces-
or most commonly in association with severe infec- sive inflammation, a second‐hit insult, or a complex
tion (septic shock). These complexities are further disturbance of proinflammatory and anti‐inflam-
reflected in the observation that different individu- matory pathways. Management of MODS contin-
als may have quite different responses to seemingly ues to be entirely supportive. While available
similar insults. clinical care and resuscitation practices reduce but
While criteria for individual organ dysfunction do not completely prevent its incidence in the
vary, overall patient mortality tends to increase patient groups at risk, there is evidence of a slow
with the number and severity of dysfunctional reduction over time in the mortality risk with
organ systems present. One widely accepted organ MODS that may be related to overall improve-
dysfunction score, used alone or in combination ments in resuscitation, surgery and critical care sup-
with other scores to predict ICU patient outcome port. However, ICU patients who survive severe
within a research or quality assurance context, is MODS may have reduced long‐term survival com-
the sequential organ failure assessment (SOFA) pared with those ICU patients who manifest less
severity of illness score. This score assesses six severe MODS.
Management of the critically ill Further reading
The detailed management of the critically ill patient Bersten AD, Handy J (eds) Oh’s Intensive Care Manual,
is the subject of a vast literature and of many sub- 8th edn. Elsevier, 2019.
Kelley MA. Predictive scoring systems in the intensive care
stantial textbooks. While this management requires
unit. UpToDate. https://www.uptodate.com/contents/
clinical experience, the general principles are
predictive‐scoring‐systems‐in‐the‐intensive‐care‐unit
straightforward, though their implementation can (accessed 28 April 2018).
be complex, sophisticated and multidisciplinary. Marino PL. Marino’s The ICU Book, 4th edn. Philadelphia:
• Resuscitation and maintenance of an optimal Wolters Kluwer Health, 2014.
blood volume is just as much a continuing prior-
ity as it is an initial goal in the treatment of the
critically ill. However, the optimal fluid status of
individual patients may be difficult to quantify.
• Treatment of respiratory impairment, together MCQs
with circulatory management, comprise the twin
pillars of life support in ICU. Abnormalities of
gas exchange and of pulmonary mechanics are
common and are often severe. Specialised and
sophisticated mechanical ventilation is the main- 1 Treatment of critically ill patients in an intensive
stay of respiratory support. care unit:
• After initial resuscitation, and while circulatory a increases the cost of care but does not improve
and respiratory support are in train, early diag- the prognosis
nosis and specific therapy (if any) are required. b is associated with an approximately 50% survival
• Optimal intensive care aims to balance simultane- rate overall
ous resuscitation, appropriate diagnostic algorithms c is associated with approximately a 5–10% death
and the provision of definitive management. rate overall
• There is much emphasis on the early treatment of d is required for 25% of all hospital patients at
sepsis and on the prevention and treatment of some point in their illness
complicating infections. e is not indicated for any patient over 80 years of age
• Metabolic support is essential, because malnutri-
tion may develop rapidly and is a covariable in 2 Infection in critical illness is:
mortality and because adequate nutrition is a almost always followed by dysfunction in
required for tissue repair. Enteral nutrition is pre- multiple organ systems
ferred if technically feasible. b only able to be diagnosed in the presence of
• Renal support may require renal replacement septic shock
therapy (most commonly with continuous veno- c rarely associated with septic shock
venous haemofiltration techniques). d rarely caused by common bacteria
• Psychosocial support is important for both the e often found in the lungs or abdomen
patient and the family. The patient requires analge-
sia, anxiolysis, comfort and dignity, and the family 3 The sequential organ failure assessment (SOFA)
requires access, information and support. Humanity score:
of care in ICU extends to end‐of‐life care in those a quantifies the overall amount of dysfunction
patients with unsurvivable conditions. across six organ systems
• Intensive care requires continuous patient man- b scores above zero nearly always imply the
agement by a skilled multidisciplinary team in a presence of invasive bacterial or fungal infection
specialised environment. Attention to detail is c rarely exceeds zero after cardiopulmonary bypass
necessary to identify problems and therapeutic procedures
opportunities as early as possible. In general, d helps in the clinical differential diagnosis between
much of the care of the critically ill is founded on infection types
complex physiological support which buys time e is based on the worst physiological disturbance in
for healing to occur. each 8 hours of a patient’s admission
4 Intravenous fluid resuscitation of hypotensive, 5 Commonly applied critical care organ support
hypovolaemic critically ill patients in hospital should involves all of the following except:
be in most cases: a mechanical ventilation for hypercarbia
a slow and gentle using only colloids b vasopressor infusions for low cardiac output
b rapid and partial using crystalloids only states
c slow and complete using colloids only c hemodiafiltration for uraemia
d rapid and complete using crystalloids or colloids d platelet transfusion for thrombocytopenia
or both e inotropic infusions for low cardiac output
e composed mostly of a solution of 4% albumin states
9 Surgical infection
Marcos V. Perini and Vijayaragavan Muralidharan
University of Melbourne and Austin Health, Melbourne, Victoria, Australia
of prophylactic antibiotics, are important factors in

Introduction reducing surgical infections.
Surgical infection refers to infections that require

surgical treatment or those occurring in the after-
math of surgery. They may occur de novo in healthy Natural barriers to infection
patients or as complications of surgical proce-
dures (postoperative infections). Most postopera- The inflammatory and immune response to a break
tive infections do not require surgical intervention. in the natural barriers in the body starts early after
However, it is important for the surgical team to be the insult. When natural barriers such as the epithe-
aware of the prevention, diagnosis and manage- lium of the skin, respiratory system, gastrointestinal
ment of such infections after a surgical proce- tract and urinary system are breached, microorgan-
dure. Surgical site infection (SSI) should always be isms are able to enter tissues locally and start the
considered high amongst the myriad of possible
process of infection. In some circumstances bacte-
postoperative infections and active management raemia may result in distal spread leading to infec-
instituted to reduce its morbidity. tive endocarditis, abscesses in solid organs (liver,
Postoperative infections occur in up to 5% of the spleen) and osteomyelitis. The protection afforded
patients undergoing a surgical procedure. The inci- against infections by the mechanical barrier (integu-
dence and severity depends on patient‐related (host) ment, mucosa) is supplemented by the immune sys-
risk factors and situational risk factors (surgeon, tem. Impairment of the immune system due to
type of surgery). Some risk factors that cannot be disease (diabetes, cancer, chronic illness), patient
avoided, such as immunosuppressed patients and factors (advanced age, malnutrition) or direct sup-
contaminated emergency procedures, increase the pression (chemotherapy, organ transplantation)
risk of postoperative complications. Some medical leads to a blunted and delayed response to infection.
conditions are associated with a high risk of post- This may also result in unusual clinical presenta-
operative infection. These include malnutrition, tions and uncommon microbes, including infections
diabetes mellitus, obesity, chronic inflammation, by commensal organisms. Imbalance of one or more
previous irradiation, advanced age, steroid therapy, components of these defences may have substantial
re‐operations and coexisting infection remote to negative impact on resistance to infection.
the surgical site. Awareness and prevention are the The skin is the most extensive physical barrier in
key factors in achieving optimum outcomes, par- the body preventing infections. In addition to the
ticularly in elective operations. mechanical barrier, local skin flora also play major
General principles and detailed evidence‐based a role in limiting the population of non‐commensal
guidelines for prevention of SSI, central line‐associ- microorganisms. The respiratory system has addi-
ated bloodstream infection and ventilator‐associ- tional defensive mechanisms against sepsis. In the
ated pneumonia have been published. Attention to upper respiratory tract, respiratory mucus traps
detail in postoperative management, with strict larger particles and microorganisms while smaller
adherence to hand hygiene and universal body fluid particles arriving in the lower respiratory tract are
precautions and avoiding under‐ and over‐resusci- phagocytosed by pulmonary alveolar macrophages.
tation, central line insertion under suboptimal con- Impairment of these mechanisms increases the risk
ditions, early removal of abdominal drains and use of respiratory infections.
65
The pancreato‐biliary ductal system, urogenital The interaction of microorganisms with the first‐
and distal respiratory tracts do not possess resident line host defences leads to microbial opsonisation
microflora in healthy individuals. Microorganisms (C1q, C3b), phagocytosis, and extracellular and
may be present if these barriers are impaired by intracellular microbial destruction. The classical and
disease or if they are introduced from an external alternate complement pathways are activated both
source. In contrast the gastrointestinal tract in a by direct contact with, and by IgM and IgG binding
normal individual teems with microorganisms, to, surface cell proteins. This releases a number of
especially in the colon. The highly acidic, low‐ different complement protein fragments (C3a, C4a
motility environment of the stomach significantly and C5a) that enhance vascular permeability.
reduces the concentration of microorganisms Bacterial cell wall components and a variety of
entering the stomach from the oropharynx during enzymes expelled from leucocyte phagocytic vacu-
the initial phases of digestion. This explains the oles during phagocytosis act in this capacity as well.
small number of microorganisms present in the The simultaneous release of substances chemotac-
gastric mucosa, amounting to approximately 102– tic to polymorphonuclear leucocytes (PMNs) in the
103 colony‐forming units (CFU)/mL. Patients bloodstream takes place. These consist of C5a,
receiving proton pump inhibitors have higher microbial cell wall peptides containing N‐formylme-
number of bacteria likely due to diminished gastric thionine, and macrophage cytokines such as IL‐8.
acidity. Microorganisms that are not destroyed in This process of host defence recruitment leads to fur-
the stomach may proliferate in the small intestine, ther influx of inflammatory fluid and PMNs into the
reaching up to 105–108 CFU/mL in the terminal area of incipient infection, a process that begins
ileum. within several minutes and may peak within hours or
In the colon, due to its low‐level oxygen status, days. The magnitude of the response is related to sev-
there is a steady growth in the number of anaerobic eral factors: (i) the initial number of microorganisms,
microorganisms and approximately 1011–1012 (ii) the rate of microbial proliferation in relation to
CFU/g are present in faeces. Large numbers of fac- containment and killing by host defences, (iii) micro-
ultative and strict anaerobes (Bacteroides and other bial virulence, and (iv) the potency of host defences.
species) and several orders of magnitude fewer aer- The inflammatory and immune response leads to
obic microbes (Escherichia coli and other signs and symptoms that will depend on the amount
Enterobacteriaceae, Enterococcus and Candida of cytokine expression and the geographical area in
species) are present. which they are released (local tissue or bloodstream).
Signs of local inflammation include pain (dolor),
warmth (calor), redness (rubor) and swelling/oedema
Pathogenesis of infection (tumor) which may progress locally to abscess for-
mation or spread to cause a systemic response.
When microorganisms enter a sterile environment Sepsis is defined as the presence of at least two
in the host (e.g. subcutaneous tissue, peritoneal or of four SIRS criteria in the setting of confirmed
pleural cavity), a non‐specific general inflammatory infection (Box 9.1). Severe sepsis is defined as sepsis
response is activated by local immune cells (resident resulting in tissue hypoperfusion or end‐organ
macrophages), complement (C) proteins and immu-
noglobulins (non‐specific antibodies). Resident
macrophages secrete a wide variety of cytokines Box 9.1 Systemic inflammatory response
that regulate the cellular components of immune syndrome (SIRS)
response. Macrophage cytokine synthesis is upreg-
ulated and includes secretion of tumour necrosis An inflammatory response that may or may not be
factor (TNF)‐α, interleukin (IL)‐1, IL‐6, IL‐8 and associated with infection. The presence of two or
interferon (IFN)‐γ within the tissue. These are pro- more of the following criteria, one of which must
inflammatory cytokines which cause vasodilata- be abnormal temperature or leucocyte count,
tion, increased vascular permeability and oedema. defines SIRS:
• Core temperature (measured by rectal, bladder,
These cytokines may sometimes initiate a cascade
oral or central probe) >38.5°C or <36°C
of inflammatory responses leading to widespread
• Tachycardia >90 beats/min
systemic effects described as systemic inflammatory
• Hyperventilation demonstrated by respiratory rate
response syndrome (SIRS). Simultaneously, a coun-
>20 breaths/min or Paco2 <32 mm Hg
ter‐regulatory response is initiated consisting of
• White blood cell count >12 × 109/L, <4 × 109/L, or
anti‐inflammatory cytokines (IL‐4 and IL‐10) in an consisting of >10% immature forms (bands)
attempt to limit the extent of the response.
9: Surgical infection 67
ysfunction. Septic shock is defined as sepsis with

d
Box 9.2 Classification of surgical wounds
persistent hypotension despite adequate fluid resus-
citation. Sepsis‐induced hypotension is defined as a Wound classification is based on the degree of
systolic blood pressure lower than 90 mmHg or a expected contamination during the surgery.
mean arterial pressure lower than 70 mmHg.
Clean
Uninfected operative wounds in which no inflamma-
tion is encountered, and the wound is closed
Surgical site infection primarily. By definition, a viscus (respiratory,
alimentary, genital or urinary tract) is not entered
Definition during a clean procedure.
SSI is the most common complication after surgery Risk of infection: 1.3–2.9%
with an overall incidence of 2–5%. It is defined as Clean‐contaminated
an infection related to an operative procedure that A viscus is entered under controlled conditions and
occurs at or near the surgical incision within 30 without unusual contamination.
days of the procedure (or within 90 days if an Risk of infection: 2.4–7.7%
implant is left in place). Clinical criteria for defining
Contaminated
SSI include one or more of the following: (i) puru-
Open fresh accidental wounds, operations with major
lent exudate draining from a surgical site; (ii) posi-
breaks in sterile technique, or gross spillage from a
tive fluid culture obtained from a surgical site that
viscus.
was closed primarily; (iii) surgical site that was reo-
Risk of infection: 6.4–15.2%
pened in the setting of at least one clinical sign of
infection and is culture positive or not cultured; Dirty
and (iv) the surgeon makes the diagnosis of infec- Old traumatic wounds with retained devitalised
tion. SSIs increase the risk of death by 2–11 times, tissue, foreign bodies or faecal contamination.
which is directly related to the infection, and have Risk of infection: 7.1–40%
an overall mortality of 3%. It is estimated that
40–60% of SSIs are preventable.
measures include cessation of smoking, nutritional
Classification (Box 9.2) supplementation and good glycaemic control in
patients with diabetes. Intraoperative measures
SSIs can be classified as incisional (in the wound)
include prophylactic antibiotics, appropriate skin
and organ/space (any part of the anatomy that was
hair removal at the surgical site, sound surgical
opened or manipulated during the operative proce-
technique, hand hygiene and selective use of drains.
dure including anastomotic leaks). The latter account
More recently, the prophylactic use of intraopera-
for one‐third of SSIs but are responsible for more
tive wound irrigation devices has shown decreased
than 90% of the deaths related to SSI. Wound infec-
infection rates compared with non‐irrigated
tions may occur at any time after the procedure and
wounds in the setting of clean‐contaminated inci-
will depend on patient status and aggressiveness of
sions. Irrigation of the surgical wound has been
the pathogen. Most wound infections will be clini-
found to offer benefits by hydrating the tissues,
cally evident between 5 and 10 days after surgery.
allowing better visualisation and removing contam-
inated material. These lower the microbiological
Pathogens
burden and expedite the healing process. However,
The most common organisms causing SSI after a no benefits have been seen when antibiotics are
clean procedure are skin flora including streptococ- added to the irrigation solution. In the postopera-
cal and staphylococcal species. In clean‐contami- tive period maintaining normoglycaemia and nor-
nated procedures, Gram‐negative bacilli and mothermia are important factors.
enterococci are predominant. When a viscus is
entered, the pathogens usually reflect the endoge- Antibiotic prophylaxis
nous flora of the viscus.
The goal of antimicrobial prophylaxis is to prevent
SSI by reducing the burden of microorganisms at
Prevention
the surgical site and to control any bacteraemia
A number of perioperative preventive measures that may occur during the operative procedure.
have been demonstrated to reduce SSI especially Repeat intraoperative doses are warranted for pro-
in major and complex operations. Preoperative cedures that exceed two half‐lives of the drug or for
procedures in which there is excessive blood loss oedema, facilitates bacterial clearance and improves
(>1500 mL). Patients receiving prophylactic antibi- management of the exudate. It promotes wound
otics 1 or 2 hours before the surgical procedure contraction to cover the defect and may trigger
have less SSIs than patients receiving earlier or later. intracellular signalling that increases cellular prolif-
There is no role for postoperative prophylactic eration. The clinical usefulness has been demon-
antimicrobial therapy in routine surgery. In selected strated in treatment of SSI (skin, subcutaneous and
cases where prophylaxis beyond the period of sur- muscular infection) and has also been applied in the
gery is considered, discussion with the infectious management of patients not amenable to abdominal
disease team should be undertaken and prophylaxis closure (laparostomy) in the emergency situation.
extended to no more than 24 hours. A multidiscipli-
nary approach including infectious disease and
cardiology teams should be adopted in patients
Central line‐associated bloodstream
with a prosthetic valve, cardiac pacemaker device infection
or previous infective endocarditis. Staphylococci
and β‐haemolytic Streptococcus species are of Central venous catheters (CVCs) are essential to
prime concern with regard to infective endocarditis. intraoperative and postoperative management of
The main oral pathogen associated with this type of sick patients and in healthy patients undergoing
infection is S. viridans. major operations. They are used widely and for
prolonged duration in patients in intensive care
Early drain removal units (ICUs) for the delivery of vasoactive drugs
and hypertonic solutions and for monitoring and
Drains are often used after major elective abdomi-
management. Central line‐associated bloodstream
nal operations, emergency surgery and thoracic
infection (CLABSI) is defined as a bloodstream
surgery (pancreas resection, total gastrectomy,
infection in a patient who had a central line in place
oesophagectomy, low anterior resections and car-
within 48 hours before the development of the
diothoracic surgery). In elective surgery, drains are
infection and in whom no other source of infection
used to remove the accumulation of inflammatory
is found. It is a significant burden on healthcare sys-
fluid and haematoma while identifying surgical
tems and is associated with increased length of stay
complications. Early drain removal policies have
in both ICU and the hospital.
been adopted in many institutions in order to
The majority (50–70%) of CLABSI cases are
expedite recovery and reduce hospital length of
thought to be preventable by using current evi-
stay. Increasingly, the use of drains is being
dence‐based guidelines. Hand hygiene has been
eschewed in many major elective operations based
shown to be a simple and safe method of preven-
on accumulating evidence (liver resections, colec-
tion but some studies show lack of compliance
tomies, large hernia repairs, partial gastrectomy
rates of up to 30%. Aseptic technique, involving
and splenectomy).
skin preparation with alcohol‐based solution and
the use of full barrier precautions (gloves, masks,
Wound breakdown
gowns), are also essentials. Choosing the ideal site
Simple surgical wound infections presenting as cel- of insertion to minimise sepsis is also important.
lulitis may be managed with antibiotic therapy. The site with the lowest infection rate for CVC
The presence of underlying collections or actual insertion is the subclavian vein, although the inter-
breakdown of part or whole of the wound requires nal jugular vein remains the most widely used site.
additional intervention. This may be radiological Patients with neutropenia, severe burns, malnutri-
or open surgical drainage of purulent material and tion and chronic inflammatory conditions are at
mechanical debridement of devitalised tissue. great risk of CLABSI. Duration of catheterisation,
Wounds opened in such a manner are managed by catheter material, insertion conditions and quality
packing and programmed dressing changes sup- of site care also affect the incidence of CLABSI.
ported by antibiotics. The source of infection in CLABSI may include
Where more intense and continuous aspiration of contamination from surrounding skin, contamina-
the exudate is warranted, negative pressure therapy tion of the CVC, colonisation of the CVC from a
(NPT) may be applied using vacuum‐assisted clo- concomitant bloodstream infection and contami-
sure wound management devices. Sealed suction is nation of the infusions. The skin flora (coagulase‐
applied continuously over the infected area in order negative staphylococci and Staphylococcus aureus)
to aspirate the purulent tissue and to avoid the crea- is the most common type of bacteria seen in blood-
tion of abscess. NPT optimises blood flow, decreases stream infection.
Treatment involves initially sampling the blood hospital‐acquired pathogens are involved. Such
peripherally, changing the catheter with the assis- widespread sepsis may require multiple laparoto-
tance of a guidewire (if there are no signs of skin mies to control the source of sepsis and can lead to
infection) and sampling the catheter tip. Broad‐ abdominal compartment syndrome, which may
spectrum antibiotics should be commenced empiri- require open abdominal wound management.
cally and modified depending on blood culture
results and clinical progress. Patients with positive
peripheral blood culture should be treated with Hospital‐acquired pneumonia
long‐term antibiotics and change of the CVC.
Hospital acquired pneumonia (HAP) is one that
occurs 48 hours or more after admission and did
Intra‐abdominal collections not appear to be incubating at the time of admis-
sion. Pneumonia is the leading cause of infectious
Most SSIs occur in the skin, subcutaneous space mortality in hospitalised patients. Surgery and pro-
and muscle close to the incision. However, organ or longed intubation are the main predisposing fac-
space‐occupying infections such as intra‐abdomi- tors. Surgical patients who undergo thoracic and
nal, intrapleural and intracranial (intracavitary) upper abdominal surgery, those requiring postop-
infections are life‐threatening events due to delayed erative mechanical ventilation and those with pre-
diagnosis and the underlying aetiology. These vious lung conditions are particularly susceptible to
include inflammatory fluid collections and haema- pneumonia. The risk of HAP increases 6 to 20‐fold
tomas that subsequently become infected and in mechanically ventilated patients, denoting that
develop into an internal abscess. Alternatively, there airway intubation itself is a major risk factor for
may be leakage of fluid from the cut surface of an postoperative mortality.
organ or an anastomosis which develops into an Ventilator‐associated pneumonia (VAP) is a sub-
infected collection. These deep infections may type of HAP that develops more than 48–72 hours
remain occult or manifest with few symptoms, after endotracheal intubation. Risk factors for VAP
mimicking superficial SSI and possibly delaying are listed in Box 9.3. The diagnosis of VAP requires
diagnosis and initial treatment. Such complications one or more of the following: fever, leucocytosis or
then become evident when major signs of a sys- leucopenia, purulent sputum, hypoxaemia, or a
temic infection become apparent (e.g. leucocytosis, new or evolving chest radiograph infiltrate. A path-
fever, hypotension, sepsis, elevated lactate and ogen does not need to be identified. Defining the
C‐reactive protein). Diagnosis often requires radio- aetiology of postoperative pneumonia is difficult,
logical evaluation. CT is the most practical choice as most patients are unable to produce an adequate
for intra‐abdominal, pelvic and thoracic collec- sputum sample.
tions. Affected patients should be resuscitated and The pathogenesis of HAP and VAP is related to
broad‐spectrum antibiotics commenced based on the numbers and virulence of microorganisms
the most likely pathogens to be found. entering the lower respiratory tract and the response
Intra‐abdominal collections are one of the most of the host. The primary route of infection of the
common complications that surgeons will face in lungs is through micro‐aspiration of organisms
clinical practice. Treatment depends on the size, which have colonised the oropharynx.
cause, underlying medical condition and systemic
status of the patient. Small collections (<4 cm) may
be treated successfully with systemic antibiotics. Box 9.3 Risk factors for VAP
Radiologically guided percutaneous aspiration and
drainage are indicated for larger localised collec- • Acute respiratory distress syndrome
tions within solid organs or the peritoneal cavity • Advanced age
with a high rate of success. For those collections • Large‐volume gastric aspiration
that are not amenable to radiological intervention, • Blood transfusion
those associated with widespread intra‐abdominal • Immunosuppression
sepsis and where a surgical procedure is warranted • Organ failure
• Coma
for other reasons, open surgical drainage is per-
• Chronic obstructive pulmonary disease
formed. This also allows high‐volume lavage of the
• Trauma
peritoneal cavity. Widespread intra‐abdominal sep-
• Burns
sis in the postoperative period has a high mortality
• Prolonged ventilation
rate of 25–30%, but may exceed 70% where
Prevention strategies for intubated patients are are recent hospitalisation, age more than 65 years
well defined and their cost–benefit proven world- and immunosuppression.
wide. The strategy involves (i) elevating the bed Symptoms of C. difficile infection (CDI) are
head to between 30 and 45°; (ii) actively lightening abdominal pain, fever, diarrhoea, blood in the stool
sedation on a daily basis; (iii) actively assessing the and leucocytosis. It is classified as severe and non‐
potential to wean or extubate on a daily basis; (iv) severe colitis. Non‐severe CDI results in watery
avoiding antacids and histamine H2 blockers unless diarrhoea (three or more loose stools in 24 hours)
clearly indicated; and (v) prophylaxis of deep vein with lower abdominal pain and cramping, low‐
thrombosis. grade fever and leucocytosis (≤15 × 109 cells/L).
The choice of the antibiotic treatment regimen Severe CDI presents with diarrhoea, severe lower
for HAP or VAP should be tailored to the patient’s quadrant or diffuse abdominal pain, abdominal
recent antibiotic therapy, resident flora in the hospi- distension, fever, hypovolaemia, lactic acidosis,
tal/ICU, degree of underlying diseases, severity of hypoalbuminaemia and marked leucocytosis (>15
illness, available blood and sputum cultures, and × 109 cells/L). Fulminant colitis is a severe episode
risk for multidrug‐resistant pathogens. Generally, that is complicated by hypotension, shock, ileus or
initial antibiotic treatment for HAP targets S. megacolon.
aureus, Pseudomonas aeruginosa and Gram‐nega- The diagnosis of CDI is established by a positive
tive bacilli. stool test for C. difficile toxin. Laboratory testing
should be pursued only in patients with clinically
significant diarrhoea, since testing cannot differen-
Catheter‐associated urinary tract tiate CDI from asymptomatic carriage that does not
infection warrant treatment. Radiographic imaging, usually
with contrast CT of the abdomen and pelvis, is
Catheter‐associated urinary tract infection (CAUTI) advised for patients with clinical manifestations of
is a common hospital‐acquired infection. The most severe illness or fulminant colitis to exclude the
important risk factors are the duration of catheteri- presence of toxic megacolon or any condition that
sation followed by errors in catheter insertion and requires surgical intervention. Colonoscopy is not
management. Classic symptoms include flank pain, needed in patients with classic symptoms, positive
suprapubic discomfort, urinary discoloration and laboratory tests and improvement after antibiotic
catheter obstruction. However, in the elderly these therapy. For non‐severe cases oral vancomycin is
often present with non‐specific findings such as the initial treatment, with metronidazole as the sec-
delirium, leucocytosis, malaise or general signs of ond choice. Surgical evaluation should be consid-
sepsis. In the presence of CAUTI the urinary cathe- ered for patients with peritoneal signs, severe ileus,
ter should be removed or (if required) replaced, a toxic megacolon, white blood cell count of 15 ×
urine sample acquired for culture, and empirical 109/L or more and/or elevated plasma lactate (≥2.2
antibiotic therapy commenced and subsequently mmol/L). The rational use of antibiotics is the
tailored based on culture results. mainstay of prevention of CDI. Faecal microbiota
Avoidance of unnecessary catheterisation, use of transplantation is currently emerging as an effective
sterile technique for insertion, and removal as soon therapy for recurrent CDI.
as possible are essential in the prevention of CAUTI.
There is no role for antibiotic prophylaxis in
patients with a urinary catheter. Necrotising fasciitis
Necrotising fasciitis (NF) (Figure 9.1) is a serious

Pseudomembranous colitis and devastating infection that can evolve rapidly
without showing any superficial physical evidence
Pseudomembranous colitis is an inflammation of of spread. NF is characterised clinically by fulmi-
the colon caused by Clostridium difficile overgrowth nant tissue destruction, systemic signs of toxicity
in the colon. It is characterised by elevated yellow‐ and high mortality. Risk factors for NF include skin
white plaques that coalesce to form pseudomem- or mucosal breach, traumatic wounds, diabetes and
branes on the mucosa. It is also known as other immunosuppressive conditions. Fournier’s
antibiotic‐related colitis due to the relationship to gangrene (Figure 9.2) is a subtype of NF originating
previous use of antibiotics. The most common anti- in the perineal area and spreading through the fas-
biotics implicated are fluoroquinolones, clindamy- cia, leading to extensive muscle necrosis. The diag-
cin and cephalosporins. Other risk factors associated nosis can sometimes be difficult, so a low threshold
bullae, necrosis or ecchymosis in the skin. Systemic

toxicity may be observed. NF usually presents
acutely and most commonly involves the extremi-
ties, with the lower extremity more commonly
involved than upper extremity. It should be sus-
pected in patients with soft tissue infection and
signs of systemic illness (fever, haemodynamic
instability) in association with crepitus, rapid pro-
gression of clinical manifestations and/or severe
Fig. 9.1 Necrotising fasciitis of the right thigh. Note that pain (out of proportion to clinical signs).
the subtle mottling and erythema of the surrounding skin The best initial radiological examiation is CT of
vastly underestimates the underlying muscle necrosis of the affected region. Presence of gas in the tissues is
subcutaneous fat and muscle. highly specific for NF and surgical exploration
should be expedited. The diagnosis of necrotising
for suspicion of this condition in patients present- infection is established via surgical exploration of
ing with perineal problems is advised, mainly when the soft tissues in the operating room, with physical
they have signs of sepsis and marked leucocytosis. examination of the skin, subcutaneous tissue, fas-
NF occurs when the bacteria enter the subcuta- cial planes and muscle.
neous layers in regions with relatively poor blood Aggressive surgical debridement and broad‐spec-
flow and hypoxia. These conditions delay the trum antibiotic therapy accompanied by intensive
immune system response and allow bacterial over- care for haemodynamic support should be offered
growth and production of toxins. These toxins promptly. Factors associated with increased mortal-
cause vasoconstriction and vascular thrombosis of ity include white cell count in excess of 30 × 109/L,
the perforating vessels, increasing hypoxia and tis- creatinine above 177 mmol/L, age over 60 years,
sue necrosis and starting a vicious cycle of hypoxia, Clostridium infection, delay of more than 24 hours
necrosis, bacterial growth and more hypoxia. NF in surgical intervention, and infection involving
may be polymicrobial (type 1) or monomicrobial head, neck, thorax and abdomen.
(type 2). The former is caused by aerobic and anaer-
obic bacteria, usually occurring in older adults or
Antimicrobial resistance and antibiotic
diabetic patients. Type 2 NF is most commonly
stewardship in surgery
caused by group A Streptococcus and other
β‐haemolytic streptococci. It may occur in any age
The ever‐increasing number of multidrug‐resistant
group and in individuals with no underlying
microorganisms has been recognised as a grave and
comorbidities.
emergent threat to global public health (Box 9.4).
On physical examination, patients may show
There is an increasing risk of life‐threatening thera-
signs of erythema, oedema extending beyond the
peutic failures due to many drug‐resistant microbial
visible erythema, severe pain which may be out of
proportion to clinical findings, fever, crepitus, and
Box 9.4 Serious threats identified by
the Centers for Disease Control
and Prevention
• Pan‐drug‐resistant (PDR) or extended‐spectrum

drug‐resistant (XDR) Acinetobacter species
• Drug‐resistant Campylobacter species
• Fluconazole‐resistant Candida species
• Extended‐spectrum lactamase‐producing
Enterobacteriaceae (ESBLs)
• Vancomycin‐resistant enterococci (VRE)
• Multidrug‐resistant Pseudomonas aeruginosa
• Drug‐resistant non‐typhoidal Salmonella species
• Drug‐resistant Salmonella
• Meticillin‐resistant Staphylococcus aureus (MRSA)
• Drug‐resistant Streptococcus pneumoniae
Fig. 9.2 Fournier’s gangrene involving the scrotum and • Total drug‐resistant Mycobacterium tuberculosis
right buttock
infections. These result in prolonged hospital stay, Leaper DJ, Edmiston CE. World Health Organization:
higher cost of alternative therapy and increased global guidelines for the prevention of surgical site
mortality. infection. J Hosp Infect 2017;95:135–6.
Although much of the effort on responsible antibi- Mazuski JE, Tessier JM, May AK et al. The Surgical
Infection Society revised guidelines on the management
otic stewardship has focused on primary care provid-
of intra‐abdominal infection. Surg Infect (Larchmt)
ers, there is a significant opportunity for surgeons to
2017;18:1–76.
contribute, as antibiotic misuse appears to be quite Rhodes A, Evans LE, Alhazzani W et al. Surviving sepsis
common. Potential areas for surgical antimicrobial campaign: international guidelines for management of
stewardship supported by evidence are as follows. sepsis and septic shock: 2016. Intensive Care Med
• Discontinuation of antibiotics after routine elec- 2017;43:304–7.
tive surgical cases. Prolonged postoperative use
does not prevent SSI.
• No role for topical wound site antibiotics when MCQs
systemic preoperative antibiotic prophylaxis is
administered. Select the single correct answer to each question. The
• Limited, fixed courses of antibiotics are adequate correct answers can be found in the Answers section
for treating complex intra‐abdominal infections at the end of the book.
after the source control has been achieved. 1 Which of the following statements is true?
• Antibiotics are not required after incision and a use of alcohol‐based solutions on surgical site
drainage of superficial skin abscesses and open- skin does not change the SSI rate
ing of infected superficial SSIs. b hand wash has poor compliance in most of the
• Uncomplicated diverticulitis does not require studies
antibiotic therapy. c sterile technique is not warranted to insert a
• Bacteriuria in patients without frequency, urgency, central venous catheter
dysuria or unspecified suprapubic pain (asympto- d use of prophylactic antibiotics during elective
matic) does not constitute a urinary tract infec- surgery is not necessary
tion and should not be treated with antibiotics. e for most skin infection, cefazolin‐based
• Presence of C. difficile in stool samples in the antibiotics are warranted as they target the
absence of clinical symptoms should not be Gram‐negative skin flora
treated with antibiotics.
2 Regarding the immune response to infection, which
statement is true?
Summary a resident inflammatory cells do not play a role in
the development of infection
Infection is a major cause of surgical morbidity and
b proinflammatory cytokines such as IL6‐ and
is multifactorial. Hand washing, universal body
IL‐10 are produced locally
fluid precautions and attention to surgical tech-
c anti‐inflammatory cytokines are produced in
nique are the factors that surgeons may implement
response to infection and can lead to chronic
to reduce the infection rate. Attention to patient
infection when overproduced
(host) factors that may be improved (nutritional
d alternative complement cascade is activated by
status, anaemia, sarcopenia) prior to surgery,
direct contact with type 2 antigen‐presenting cells
awareness of high‐risk patients and strict imple-
e all of the above are correct
mentation of perioperative preventive strategies
will help reduce the incidence, morbidity and mor-
3 Which of the following is a true statement?
tality of surgical infections.
a sepsis may occur in the absence of SIRS
b surgical infection is diagnosed only when
bacterial overgrowth is documented
Further reading c SSI occurs only in the first 7 days after an
operation
Adamina M, Kehlet H, Tomlinson GA, Senagore AJ,
Delaney CP. Enhanced recovery pathways optimise d SSI only applies to infections that occur in the
health outcomes and resource utilization: a meta‐analysis skin and subcutaneous tissue
of randomised controlled trials in colorectal surgery. e intra‐abdominal abscess after an abdominal
Surgery 2011;149:830–40. operation is classified as SSI
4 Regarding surgical infections, which of the e catheter‐associated infection is more common

following is true? when the central line is inserted in the jugular
a necrotising fasciitis is called Fournier’s gangrene area than the subclavian area
when the infection dissects the deep neck fascia
towards the upper mediastinum 5 Perforated appendicectomy wounds are classified
b necrotising fasciitis is easily diagnosed with as being:
ultrasound scan a clean
c pseudomembranous colitis is an infection b clean‐contaminated
characterised by diffuse involvement of the colon c contaminated
d pseudomembranous colitis is diagnosed by stool d contaminated‐dirty
samples that are incubated for 24–48 hours and e none
show Clostridium difficile overgrowth
10 Transplantation surgery
Michael A. Fink
University of Melbourne and Austin Health, Melbourne, Victoria, Australia
often used as a bridge to transplantation. The artifi-

Introduction cial pancreas is under development but is not yet
used in standard practice.
Transplantation is the implantation of an organ,
Assessment of the benefit of transplantation
part of an organ or tissue derived from one indi-
needs to take into account the survival of the
vidual into another individual. The indication is
potential recipient with and without transplanta-
most commonly chronic or acute organ failure, but
tion. Modelling of survival of patients with organ
liver transplantation is also performed for meta-
failure can be helpful in making these assessments.
bolic diseases and some forms of malignancy.
For example, the model for end‐stage liver disease
Transplantation of all organs has been shown to
(MELD) score, which was originally developed to
improve survival and quality of life of recipients.
assess the mortality risk of patients with cirrhosis
Aspects that have elements common to transplanta-
undergoing TIPS, has been validated as a prognos-
tion of all organs include recipient assessment,
tic indicator for patients with end‐stage liver dis-
organ donation, recipient selection, transplantation
ease on the liver transplant waiting list. It has
surgery, post‐transplant management including
been shown that the risk of liver transplantation is
immunosuppression, and complications.
not justified for patients with a MELD score less
than 15, but that the benefit of transplantation
increases for patients with increasing MELD
Recipient assessment scores above this.
Recipient selection should take account of the
Recipient assessment takes into account the need for expected utility of transplantation. Transplantation
transplantation, and thus the natural history of the requires either using the precious resource of
disease for which transplantation is contemplated, deceased donor organs or putting a living donor at
and the expected outcome, or utility of transplanta- risk of morbidity and mortality and therefore it is
tion. Without transplantation, some forms of organ important that the expected outcome of transplan-
failure can only be managed in a supportive fashion. tation justifies this. Potential transplant recipients
For example, liver failure is managed by endoscopic therefore undergo a process of evaluation that
surveillance and ligation of oesophageal varices, includes assessment of factors that might impact
antibiotics to minimise the development of encepha- on post‐transplant outcomes. This includes assess-
lopathy, and diuretics, ascitic drainage procedures ment of fitness for the transplant operation, such
and sometimes transjugular intrahepatic portosys- as assessment of cardiac and respiratory function.
temic shunts (TIPS) to manage ascites. None of these In addition, psychological and social factors that
interventions actually reverses the underlying pro- might impact on post‐transplant outcomes, such as
cess of liver failure. There is no reliable method of adherence to immunosuppression medications,
organ support for liver failure. Likewise, respiratory investigations and clinic follow‐up, are assessed.
failure can be managed by oxygen therapy, but there The decision to list a patient for transplantation is
is no viable long‐term mechanical alternative. On made in the context of a multidisciplinary assess-
the other hand, in the case of chronic renal failure, ment. In the setting of acute organ failure, where
organ support is available in the form of haemodi- the patient’s life is at imminent risk, the assessment
alysis and peritoneal dialysis. Ventricular assist process needs to be undertaken in a more urgent
devices are available for cardiac failure and are fashion.
75

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Textbook of Surgery

Contributors, viii 16 Peptic ulcer disease, 133

32 Large bowel obstruction, 285 Section 11 Orthopaedic Surgery

Homayoun Zargar and Anthony J. Costello

67 Obstructive jaundice, 643 76 Massive haemoptysis, 707

Alexios A. Adamides Andrew Bui

Ahmad Aly Adele Burgess

Christine Chen Andrew Danks

Peter F. Choong Anthony Dat

Christopher Christophi AM Stephen A. Deane AM

Scott K. D’Amours Jonathan Foo

Michael J. Grigg Andrew H. Kaye AM

Ian Hastie John Laidlaw

Rodney T. Judson Mehrdad Nikfarjam

Stephen O’Leary Jeffrey V. Rosenfeld AC, OBE

Kurvi Patwala Hani Saeed

Marcos V. Perini Gurfateh Singh Sandhu

Jeffrey J. Presneill Shomik Sengupta

Kenny Rao Rose Shakerian

Fairleigh Reeves Susan Shedda

Head, Department of Cardiothoracic Surgery, Ioana Tichil

act of placing a signature on a form. That signature

Usually associated with minimal blood loss. Evaluation of the elderly

Once in hospital, and particularly once under

can, when used appropriately, significantly reduce

Table 1.1 Risks of postoperative surgical site infection.

Wound infection rate (%)

Without prophylactic With prophylactic

Clean No contamination; gastrointestinal, 1–5 0–1

Table 1.2 Prevention of deep vein thrombosis.

Operative risk factors

Pre‐existing medical comorbidities Diabetes mellitus

Patients with obstructive jaundice (see through such physiological mechanisms as

Woodhead K, Fudge L (eds) Manual of Perioperative Care:

All surgical patients must be in a relaxed state of MCQs

3 Which of the following constitutes the legal standard

For most surgical procedures the benefits of per-

complications and other risks of surgery or inter-

Table 2.1 Overview of the morbidity and mortality of common surgical procedures.

Surgical procedure Morbidity (%) Mortality (%)

Inguinal hernia repair 8–32 0–0.5

There are a number of common comorbidities Neurological risk assessment

Renal risk assessment

anaesthetists but also general practitioners, general

Box 3.1 Factors associated with Box 3.2 Preoperative fasting

Breathing (lung disease)

Table 3.1 American Society of Anesthesiologists Physical Score (ASA‐PS).

ASA‐PS class Definition Examples

ASA I Healthy Healthy, non‐smoking, minimal alcohol use

assessment, patients should be allocated a score using

anaesthetist by the end of the procedure. In check-

Mobilisation Prophylaxis against venous

hyperinflation (inhalation spirometry and physio-

Fluid balance Sodium 135 10

Table 4.2 Approximate electrolyte concentrations.

Sodium Potassium Chloride Bicarbonate Hydrogen

decompression of the stomach. Unfortunately, frequency in the patient undergoing an emergency

Between days 2 and 5

Vomiting the dissection is difficult and the appendix is

seroma formation; and (iv) providing wound sur

which is reflected in an increased risk of SSI follow

ysfunction. Septic shock is defined as sepsis with