1. بسم الله الرحمن الرحيم

2. Pre-operative care

3. Preoperative Care Diagnostic Work Up (Investigations).
Preoperative Assessment (evaluation).
Preoperative Preparations
Counseling.
On going to theater.

4. Diagnostic Workup Investigations
Determine the cause and extent of the illness

5. Investigations General:
Done to all patients depending on other factors than the surgery scaduled. (cardiac, renal…….).
Specific:
Related to the scaduled surgical procedure. (partial laryngectomy need pulmonary function).

6. Pre-operative Investigations
General:
1- CBC all patients.
2- Clotting screen all patients and those on anticoagulants.
3- Hepatitis & HIV viruses secreening.
4- ECG all patients > 40Ys.
5- Echocardiogram Abnormal ECG, ischemic heart….
6- Chest x-ray All patients >30Ys.
7- Blood sugar level.

7. Pre-operative Evaluation
General
Specific

8. Pre-operative Evaluation
General
This include the following:
1-General condition of the patient.
2-Psychological condition. ( Specially in major operations).
Overall assessment of patient’s health
Identify significant abnormalities that may increase operative risk
Should begin with a complete history and physical evaluation

9. Specific
This include the following:
1-Related to anaesthesia. Air way. Evaluation by the anesthesiologist
2-Related to the surgery. Class and grade of surgery.

10. Risk Anaesthesia: 1- Airway. 2- ASA grading. Surgical:
1- Grade & type of surgery.
2- Site of surgery.

11. Specific Factors Affecting the Surgery
History of angina or infarction
History of anemia, lung disease, kidney disease, bleeding problems
Nutritional status

12. Pre-operative counselling
Ensure that indication for operation is still valid.
Identify any other medical condition.
Discuss options with patient / relatives.
Consent.
Prophylactic antibiotic
Prophylactic against DVT.
Pain control.
Nutrition.
Discussed with patient & his relatives.

13. Routine Preoperative care for the Adult Patient
Avoid taking aspirin or aspirin-containing products for 2 weeks prior to surgery unless approved by physician
2. Discontinue nonsteroidal anti-inflammatory medications 48 to 72 hours before surgery
3. Bring a list or container of current medications
4. Sedation and pre-op anesthetic medications

14. Prepare blood (if necessary) Hydration and IV access
5. Prophylactic antibiotics
6. Instruct the patient to bathe/shower the evening before or morning of surgery. Men should be cleanly shaved.
7. Nothing by mouth at least 8 hours before surgery
Prepare blood (if necessary)
Hydration and IV access
Consent for surgery

15. On going to the operating room
He/she will have to remove:
1. Dentures
2. Glasses/contact lenses
3. prosthesis
4. Makeup/nail polish

16. Factors Affecting Wound Healing
Steroids
Malnutrition
Radiation
Diabetes

17. Factors Leading to Postop Infection
Diabetes
Renal failure
Steroid medications
Immunosuppressive agents
Smoking
Preoperative infection

18. Classification of Operations
Clean Surgery.
Clean-Contaminated.
Contaminated.
Dirty.

19. Grades of Surgery
Grade I (Minor) Excision of a skin lesion or drainage of abscess.
Grade II (Intermediate) Tonsillectomy, correction of nasal septum, arthroscopy…….
Grade III (Major) Thyroidectomy, total abdominal hysterectomy….
Grade IV (Major+) Radical neck dissection, joint replacement, lung operations…

20. Grades of surgery This can help in estimating: 1- Expected time.
2- Morbidity & risk.
3- Need for blood transfusion.

21. Postoperative Care & postoperative complications

22. The aim of postoperative care is:
To provide the patient with as quick, painless and safe a recovery from surgery as possible.

23. Postoperative Care Pain management Postoperative fever
Recognize postoperative complications

24. Immediate Postoperative Period:
Anesthesiologist in charge of cardiopulmonary functions

25. Immediate Postoperative Phase Recovery Room, ICU
ABCs of Immediate Recovery period airway breathing Consciousness Circulation system review

26. Discharge from the recovery room, ICU
Vital signs Controlled pain Awake Gag reflex returned Respirations and circulatory function normal

28. Surgeon responsible for all the rest

29. Surgeon’s Responsibilities Post Operative Checks
Note time of return, note level of consciousness, monitor vital sign • Check dressings, location • Check incision, report drainage, redness, edema • Check IV site • Report kinked tubing

30. • Check pulses distal to op. site. • Measure and record 1st
• Check pulses distal to op. site. • Measure and record 1st. Void, report flatulence. • Learn type, purpose, location of all tubes, and how to empty. • Report change in character of drainage, notify nurse of need for dressing change. • Report changes in skin color. • Equipment- report if disconnected or malfunctioning.

31. Position in bed Mobilization Medications Diet

32. Fluid balance, electrolytes Respiratory care

33. Postoperative Phase Level of consciousness, movement, sensation
Skin color, temperature, nailbeds, oxygen saturation
Lungs sounds, pulses, heart rate.
Inspect abdomen for distention, monitor return of
bowel sounds, ask about flatus

34. Pain control. Comfort measures: reposition, oral care, hygiene.
Monitor dressing.
Empty drainage tubes.

35. Turn, cough & deep breathing; incentive spirometry every hour
Turn, cough & deep breathing; incentive spirometry every hour. early ambulation. Monitor output – minimum of 30cc/hr; should void within 8 hours of surgery

36. NPO until ordered, start with clear liquids – full liquids – soft diet Monitor closely for signs of infection Administer medications as ordered-antibiotics.

38. Pain Management Essential part of postoperative management
Pain can increase risk of complications
Pain relief- Multimodal
E.g. PCA, IM pethidine, oral analgesics

39. Postop Fevers
An important sign of postoperative complications. History Examination Investigations (to confirm the diagnosis) Many possible DDX. Time of onset may guide the management.

40. 3-7 days: infections like:
First 48hrs
Atelectasis
Transfusion rx
Pre-existing infection
3-7 days: infections like:
UTI, wound infection, Catheter related phlebitis , pneumonia, anastomotic leakage

41. About 7 days onwards Abscess formation Allergy to drug
Transfusion related fever
DVT/PE

43. Postop Complications General Specific
Complications do occur, but many are preventable!

44. General
Important examples: MI
pneumonia
DVT/Pulmonary embolism
CVA

45. Specific Examples: anastomotic leakage abscess formation
wound infection
ileus
bleeding

46. Wound complications
Postoperative urinary retention
Respiratory complications
Postoperative parotitis
GIT complications

47. Wound complication Wound infection Wound hematoma Wound seroma
Wound dehiscence

48. Wound infection Operative wound classification : I clean 3.3-4 %
II clean-contaminated %
III contaminated &
IV dirty (infected) %

49. Wound infection Clinical manifestation : pain swollen & edematous
redness & cellulitis
warm to touch

50. Wound infection Wound infections are classified as : Minor
( purlent material around skin suture sites)
Major
( discrete collection of pus within the wound )

51. Wound infection Wound infections are classified as :
Superficial infection
( limited to skin & subcutanous tissue )
Deep infection
( involve area of the wound below the fascia )

52. Wound infection Prevention : Skin preparation Bowel preparation
Prophylactic antibiotic
Meticulous technique
Appropriate drainage

53. Wound infection Management : Incision should be opened for drainage
Debridement if there is necrosis
Antibiotic if there is cellulitis

54. Wound Hematoma Caused by inadequate hemostasis Good media for bacteria
Manifested by pain & swelling
Drain should be used
Must be evacuated in certain location
The wound should be opened in OR

55. Wound Seromas Are lymph collections
Operation in which large areas of lymph-bearing tissues are transected
Closed-suction drain with pressure dressing
Repeated aspiration is indicated
Fertile ground for bacteria

56. Wound Dehiscence Dehiscence
( is separation within the fascial layer , usually of abdomen )
Evisceration
(extrusion of peritoneal contents through the fascial separation)
Incidence : 0.5 – 3.0 % in all abdominal procedures .

57. Wound Dehiscence Related factors : Imperfect technical closure
Increased intra-abdominal pressure from bowel distention, ascites, coughing, vomiting, or straining
Hematoma with or without infection
Infection
Metabolic diseases such as
diabetes mellitus,
uremia,
Malignant disease,
Radiation

58. Wound Dehiscence
Detected by the classical appearance of salmon colored fluid draining from wound occurs in about 85 % of cases about fourth or fifth postoperative days
Present late as an incisional hernia

59. Wound Dehiscence
Complete repair , the skin and subcutaneous tissue, facial layers closed.

60. Urinary retention Incidence : major abd. Surgery : 4 – 5 %
Anorectal surgery : > 50 %

61. Urinary retention
Stress ,pain ,spinal anesthesia & anorectal reflexes lead to increased Alpha-adrenergic stimulation , which prevent release of musculature around the bladder neck
Urgency ,discomfort , fullness ,enlarged bladder
Catheterization to relive retention

62. Respiratory complication
5 – 35 % of postop. Deaths
Predisposing factors :
smoking , age ,
obesity , COPD ,
cardiac disease

63. Respiratory complication
Atelectasis
Aspiration
Pulmonary edema
Pulmonary embolism

64. 1) Atelectasis : Collapse of alveoli
Anesthesia , postop. Incisional pain
Lung inflation in postop. period

65. 2) Aspiration : During induction of anesthesia
CXR show progression of local damage & infiltration
Prevention is only effective treatment

66. 3) Pulmonary edema :
Most common causes are fluid over load or myocardial insufficiency
Occur during :
* resuscitation
* postop. Period

67. 3) Pulmonary edema :
Simple therapy including O2 , digitalization & upright position

68. 4) Pulmonary embolism : 100’000 patients died in US per year
90 % originate from DVT of iliofemoral ves.

69. 4) Pulmonary embolism :
Mild tachypnea to sudden cardiopulmonary arrest
Diagnosis require combination of :
- ABG
- CXR
- ECG
- Doppler studies for lower extremities
- Radionucleotide ventilation – perfusion scan

70. 4) Pulmonary embolism : Management options :
* intensive supportive measures & resuscitation.
* direct or systematic thrombolysis.
* surgical pulmonary ebolectomy.
* IVC filter.
Prevention of PE by using mechanical devices or pharmacologic inhibition of coagulation

71. Postoperative Parotitis
Serious complication
High mortality rate
Rt. & Lt. equally involved
Bilaterally 10 – 15 % of cases
75 % of patients are 70 year or older
Poor oral hygiene , dehydration , use of anticholinergic drugs

72. Postoperative Parotitis
Majority of infections are from staphylococi
Lack of oral intake to stimulate parotid secretions predisposes to bacterial invasion of Stensen’s duct
Interval between operation & the onset varies from hours to many weeks

73. Postoperative Parotitis
Present with :
pain in the parotid region
swelling & tenderness
cellulitis on face & neck
temperature & leukocyte high
Prophylaxis includes adequate hydration & good oral hygiene

74. Postoperative Parotitis
Antibiotic should be started against staphylococi
Surgical drainage
( by incision made ant. to ear extending to mandible angle )
In 80 % of patient treated with incision & drainage the parotitis was palliated or cured

75. GIT complications
Ileus
Anastomotic leaks
Fistulas
Stomal complication

76. 1) Ileus :
Non-mechanical obstruction that prevents normal postop. Bowel function
Arise from neural inhibition of bowel motor activity & effective peristalsis
Increased with manipulation ,inflammation , peritonitis & blood left in peritoneal cavity

77. 1) Ileus : Blood in retroperitoneum often produces ileus
Hypokalemia , hypocalcemia , hyponatremia & hypomagnesemia prolong postop. Ileus
Treatment is purely supportive

78. 2) Anastomotic leaks : The etiology factors : 1) poor surgical tech.
2) distal obstruction
Risk increase with S.Albumin < 3.0 mg/dl

79. 2) Anastomotic leaks :
Three technical factors play roles in a proper anastomosis :
1- both end of bowel should have adequate blood supply
2- anastomosis should lie in tension-free manner
3- adequate hemostasis

80. 3) Fistulas : Abnormal communication between two epithelial surfaces
Common problem of GIT surgery
Can occur between :
( enterocutanous fistula ) , ( enteroenteric fistula )
( enterovesical fistula ) , ( enterovaginal fistula )

81. 3) Fistulas : Most common cause is anastomotic leakage
Persistence secondary to ( FRIEND )
( F.B. , Radiation , Infection , Epithiallization , Neoplasm , Distal obstruction )
Spontaneous closure usually occurs within 5 weeks with adequate nutrition
If persist >5 weeks operation is indicated

82. 4) Stomal complications :
Stomal necrosis & retraction
( inadequate blood supply lead to ischemia )
Stomal stricture
( late complication , caused by development of serositis )
Peristomal hernia & prolapse
( resecting the stomal prolapse & fixing it again in place )
Skin complication

83. “ Surgical Drains”

84. Why use Drains ?
Haematoma
Other Fluids (serous, chyle, pus, etc)

85. Drain…. Indications : Life saving measure : Therapeutic benefit :
Tension pneumothorax .
Therapeutic benefit :
Chest drainage : haem\ pneumothorax , empyema .
Thoracotomy , cardiothoracic procedure , oesophegeal resection and perforation .
Drainage of abscess and infected cyst .
Drainage gastrointestinal , biliary and pancreatic fistula .
Drainage after extensive dissection and elevation of skin flaps .
After operation for injury to solid organs and partial excision of these organs .
After pancreatic necrosectomy .

86. DRAINS What kind of drain you need and which size ?
The drain should be :
Soft to avoid tissue injury .
Non-irritating .
Firm….incompressible .
Resistant to decomposition .
Smooth for easy removal .

87. The Perfect Product Greater tissue contact Inert material.
Slides smoothly past any tissue
Promotes ease of movement and deep breathing
Minimal pain on removal
Comes in various sizes

88. Drain material
Latex rubber ( red rubber)…soft , but excites a profound inflammatory reaction within 24 H. .
Polyvinyl chloride (PVC) …less reactive and incompressible , however , tend to harden and splite with prolonged use, especially when in contact with bile .
Silicon ( best drain material ) least reactive and the most pliable, and show no tendency to harden with prolonged use .

89. Drainage systems Open ( static) drainage ;
Penrose , multitubular ,corrugate
Closed siphon drainage :
Closed suction drainage :
Low negative-pressure ( -100 to –150 mmHg ) e,g, Portovac , Reliavac .
High negative-pressure ( -300 to –500 mmHg )e,g. Redivac , .
Sump suction drainage : for irritant discharge .
Underwater seal drainage .

90. Type of Drains
Suction
Non - Suction
Via wound
Separate site

91. Principles of Drain Placement
Maximum area
Minimal trauma (nerves, vessel repair )
Gravitational
Patient comfort
Ease of removal

92. Packs Abscess cavity Infected wound Must contain an anti septic
must be replaced frequently.

93. wicks
Fistulae.
Discharging sinuses.
Same principles of packs.

94. Corrugated rubber drain
Sheet drainage
Simple insertion, care and removal .
Not expensive.
Tissue irritant.

95. Tube drain
Most effective method of drainage.
Closed drainage.

96. Suction machines can be connected intermittently.

97. Problems with Drains Obstruction Suction system Diameter vs Fluid
Patient mobility
Removal

98. Wound principles

99. Skin Placement

100. Suction Channels

101. Drain Length

102. Placement

103. Trochar removal

104. Fixation

105. Suction “Tip”

106. Suction adaption

107. Skin Closure

109. Drain “Organiser”

110. Patient issues Post Op

111. THANK YOU