Introduction

Your surgical placement is likely to be one of the most demanding periods of your Foundation training. Few other specialties will give you such a pivotal role in the team. Though this may seem daunting, it will be one of the best learning experiences you will have, from which you can take multiple transferable skills relevant to any specialty you wish to pursue.

In this chapter we will explore the main tasks you can expect to face in your surgical job, giving practical tips and advice to guide you in becoming a proficient, confident, multi-tasking junior surgeon. Essentially, you will be required to handle any medical issues the patient develops during their admission and escalate to the relevant medical teams as necessary.

Preoperative care

All patients undergoing elective surgery will be assessed preoperatively, usually in pre-assessment clinics a few weeks prior to surgery but also on the ward if admitted in advance. You may be involved at either or both of these stages; however, the points to consider when clerking are the same for both.

Clerking

• Patient details (name, DOB, hospital number)
  
• Procedure planned + indication
  
• History of presenting complaint:
  
  
  
  • Has the clinical picture changed significantly from when the patient was booked for surgery?
    
  • Note down relevant reports of scans/blood tests and other investigations

• Fitness for surgery + anaesthesia:
  
  
  
  • Past medical + surgical history
    
    
    
    • If possible, obtain operation reports from prior surgery. This will help in planning of surgical technique and may note previous adverse events, including anaesthetic risks. They are often filed in the patient’s old notes. Previous deep venous thrombosis (DVT)/pulmonary embolism (PE) and treatment given.
      
    • Methicillin-resistant Staphylococcus aureus (MRSA) status.
      
    • Obstructive sleep apnoea – patients may be on nightly continuous positive airway pressure (CPAP) which will be required post-operatively so planning is needed to ensure equipment is available (patients often bring their own CPAP device).
      
    • Patient’s cardiac history – previous myocardial infarction (MI)/ischaemic heart disease, echo results and left ventricular ejection fraction %.
    
    
  • Drug and allergy history
    
    
    
    • Allergies to dressings, latex, reactions to anaesthesia, antiseptic preparations (chlorhexidine/iodine) and antibiotics.
      
    • Anticoagulant/antiplatelet medications and when these have been stopped.
      
    • Steroids (they may need extra at the time of surgery).
      
    • Diabetic medication (they may need a sliding scale preoperatively).
      
    • Antiepileptics – note date of last seizure as perioperative bridging with IV valproate or phenytoin may be required
      
    • Contraception and hormone replacement therapy – increased risk of DVT/PE in major/lower limb surgery.
    
    
  • Weight
    
    
    
    • If BMI is high, special operating tables may need to be used so inform theatre staff in advance.
    
    
  • Smoking history
    
    
    
    • Consider optimizing oxygenation preoperatively, proven to improve outcomes, and ensure nicotine patch prescribed post-operatively.
    
    
  • In women of childbearing age
    
    
    
    • Date of last menstrual period.
      
    • Contraception.
      
    • Exclude pregnancy. Always get a urinary beta-human chorionic gonadotropin (bHCG) and document in notes. Some trusts also require serum levels of bHCG.
      
    • It is good practice to determine the ASA (American Society of Anesthesiologists physical status classification system) grade to assess fitness for surgery.
    
    
  • Examination
    
    
    
    • Check observations carefully, especially blood pressure. This may be the first time they are having it checked.
      
    • Perform a general physical examination, noting any cardiac murmurs, abnormal breath sounds, etc.

Address any questions or concerns the patient may have. Although the procedural details, indication, risks and benefits should have been discussed by a surgeon in clinic, the anxiety of impending surgery may result in these being forgotten. Explain the procedure and address concerns, but if unsure, reassure them that a senior colleague will come to explain further. Do not be surprised if you have patients arrive on the morning of surgery having decided they do not want to go ahead, after all of your previous efforts! Above all, ensure that they are making a fully informed decision. Usually such changes of heart are temporary and simply require reassurance. Having said that, they are perfectly within their rights to change their minds, even if they have previously signed a consent form. In these cases, you should inform your seniors early so they can make alternative treatment arrangements and adjust the operating list as required.

Check if the patient has any current/recent symptoms of viral illness, for example, cough, sore throat, diarrhoea and vomiting. Depending on the procedure planned, patient fitness and anaesthetic risks, this may be a contraindication to proceed. Notify the consultant surgeon and anaesthetist immediately if you are concerned.

Preoperative tests

For a comprehensive guide to which tests to perform in different grades of surgery and patient ASA grade, consult the latest NICE guideline (Clinical Guideline 3 – Preoperative Tests, June 2003 – The use of routine preoperative tests for elective surgery).

You should consider requesting the following:

• Blood tests
  
  
  
  • Full blood count (FBC) – baseline haemoglobin (Hb) in case of bleeding and white cell count if infection is suspected
    
  • Sickle cell screen in North African, West African, South/sub-Saharan African, Afro-Caribbean ethnic groups, Eastern Mediterranean and Middle Eastern groups. Ensure that counselling services are available in case of a positive test result
    
  • Urea and electrolytes (U&E) – if suspected/known renal impairment; if taking steroids, diuretics and angiotensin-converting enzyme inhibitor, prior to aminoglycoside use
    
  • Liver function test (LFT) – if known/suspected hepatic impairment, prior to antibiotic prescription
    
  • Coagulation studies
    
  • Random blood glucose
  
  
• Group and save (G&S) and crossmatch (see the following table).
  
• Plain chest radiograph – age >60 years, unexplained shortness of breath, cardiorespiratory disease, malignancy and thoracic/upper GI surgery. The Royal College of Radiologists advises against routine chest X-ray use in a pre-op setting for young, healthy individuals.
  
• Resting electrocardiogram – age >50 years, cardiovascular disease, diabetic and smoker.
  
• Urinalysis.
  
• Cardiopulmonary co-morbidities may necessitate arterial blood gas, exercise testing, echocardiography and pulmonary function tests – for ASA grades 2 and 3.

Requesting blood preoperatively

Check local hospital guidelines on transfusion requirements for specific procedures but the commonly requested amounts are presented in the following table. There is no evidence-based justification for routine G&S in all surgical cases; therefore, check with your consultant and local transfusion policy and send if needed.

Timing of G&S requests should also be considered. Bear in mind it takes a minimum of 45 minutes for a full crossmatch, often longer in practice in a busy blood bank. Some blood banks require two separate G&S samples to be sent for each patient at separate times before they will issue type-specific blood. Check with your hospital how long preoperative blood samples are saved and valid for. On average, G&S samples are saved for 14 days; however, a history of recent blood transfusion complicates matters and will require an up-to-date sample to be taken as follows (timings may vary).

Preoperative fasting

To reduce the risk of aspiration during anaesthesia, patients are fasted preoperatively. Traditionally, a ‘nil by mouth from midnight’ approach was taken, but now, the general rule is no oral intake of solids for ≥6 hours prior to induction of anaesthesia. Only clear fluids are allowed within 2–6 hours of surgery, that is, water/black tea/coffee. Chewing gum and soluble mints/sweets are the equivalent of eating in terms of producing gastric juices; therefore, ensure they are avoided for ≥6 hours. Many cases have been cancelled because of missing the occult gum-chewing patient!

The above timings are the absolute minimum times for elective cases. In absolute emergency, rapid sequence induction can be carried out regardless of fasting time, involving complete paralysis and maintained cricoid pressure to reduce the risk of passive gastric reflux. However, aspiration risk can still be high and rigorous oropharyngeal monitoring and suction may be needed during recovery.

Factors that increase the risk of aspiration include:

• Pregnancy
  
• Obesity
  
• Elderly
  
• Gastric disorders: hiatus hernia and gastro-oesophageal reflux disease
  
• Pain + opiate use

Consent

Obtaining consent is an art combining communication skills, surgical knowledge and perception. It takes practice and the best way to learn is to watch your senior colleagues in action.

Do not think of obtaining consent as an isolated process where a patient signs a piece of paper moments before being wheeled away, though this has been known to happen in practice. It is advisable to take the time to discuss the patient’s overall management, not just this procedure, and ensure they are fully informed of the plan, including alternative treatments. Although this may have been explored prior to admission, unless the patient is aware and understands the plan at the time of surgery, consent would not be valid. Written consent alone is not legally adequate proof of consent. It takes time for these discussions, but you benefit by developing your relationship with the patient. Unless the patient objects, it is usually best to have a member of close family present during the consent process. This helps the family to understand the process and risk, and it also helps in building the therapeutic relationship that will be important for the remainder of their treatment.

Before embarking on consenting a patient, consider the following: firstly, are you the right person to be obtaining consent? You should only accept this responsibility if you are performing the procedure, are able to do the procedure yourself or are satisfied that you know fully the indications and potential complications. It is still the responsibility of the operator, however, to ensure that adequate consent is given. If you are not happy signing the form, that is perfectly acceptable. Do not be pressured or rushed into doing it by seniors. The deaneries take a very hard line on this and you are likely to be specifically asked at your annual review whether you were ever put in a situation where you were asked to obtain consent at a level beyond your competency.

To help with the consent process, use language that the patient can understand. The patient should have an understanding of every word that you use – do not forget that phrases such as ‘anterior, supine, intubation, etc.’ are all alien to the majority of even well-educated patients. My particular favourite is when anaesthetic colleagues tell patients they intend to paralyze them! Occasionally a little imagination and abstract analogies may be required but you must persist. Diagrams are invaluable. Practice drawing relevant anatomy and/or steps of the procedure that you can use when explaining them to patients. Alternatively, look in your department for patient information leaflets. Often they can be in different languages, ideal for when your patient does not speak English.

If you feel confident to obtain consent, fill in the appropriate consent form and sign with your name, grade and date. Obtain the patient’s signature and then document in the notes what was discussed.

There are many different types of consent forms. In general use a yellow consent form 1 for routine informed consent. If an adult patient lacks capacity and you are performing a procedure in their best interests, use a form 4. This does not require patient signature but relatives can sign to show they were involved in a discussion about care. The different forms available are as follows.

In all cases of surgery, it is important to inform patients of:

• Fatigue – length of time varies according to patient and procedure.
  
• Anaesthetic risk – anaesthetists will explore this area in detail.
  
• Bleeding – reassure patients that major bleeding is uncommon but it is a risk they should be aware of.
  
• Infection – antibiotics will be given prophylactically if the procedural risk of infection is high.
  
• Multiple drains, tubes, oxygen masks, etc. may be in place for several days post-operatively.
  
• Risk of conversion to open surgery for laparoscopic procedures.
  
• For bowel surgery, always explain the risks of colostomy/ileostomy formation and put this on the consent form.

If possible, check the actual figures for risks common to the procedure in question, both in the literature and locally.

Some of the common or serious risks of specific procedures are listed below.