How can the past medical history aid diagnosis?
Recent surgery or endoscopy needs to raise awareness regarding iatrogenic injuries to surrounding anatomical structures (e.g. bleeding or perforation).
Recent traumatic injury may predispose to undiagnosed blunt visceral injuries, e.g. blunt aortic injury, ruptured spleen, perihepatic haematomas, diaphragmatic hernias, vertebral fractures.
Any previous operation in the abdomen predisposes to adhesional bowel obstruction and herniation.
Insertion of prosthetic material, such as meshes in hernia repairs or orthopaedic metal work, can result in infection of the foreign materials.
Any previous endoluminal stenting can lead to stent obstruction or migration:
Blockage of biliary stents can lead to ascending cholangitis.
Blockage of colonic stents used for palliation in bowel cancer can cause bowel obstruction.
Migration of aortic stents used in EVAR can cause endoleaks or acute ischaemia.
Previous surgery for cancer may indicate tumour recurrence.
A history of inflammatory diseases or immunosuppression can be a predictor of abscess formation and associated complications:
Crohn’s disease: perianal fistulas or inflammatory strictures.
diverticulitis: bowel perforation or diverticular abscess formation.
How is fitness for surgery assessed during the history-taking process?
A surgical diagnosis implies a potential operative intervention. It is the surgeon’s duty to decide whether the patient is a candidate for an operation. Furthermore, the surgeon needs to consider if the patient is able to survive not just the intervention, but also any potential complications of surgery. The correct operation in the wrong patient is as dangerous as an incorrect operation in the right candidate. This is determined according to four main criteria:
Bleeding and VTE risk
Hereditary or acquired bleeding disorders (e.g. haemophilia) or thrombophilias.
Anticoagulant (warfarin and heparin) and antiplatelet medication (aspirin and clopidogrel).
Steroid use.
Platelet deficiencies.
Chronic renal disease: uraemia impairs platelet function.
Chronic liver disease: abnormal clotting factor synthesis.
Operations with high risk of bleeding will need group and save and crossmatching of blood, as well as intraoperative blood or red cell salvage equipment for autologous transfusion.
Anaesthetic risk
Any cardiac or respiratory disease can increase anaesthetic morbidity.
Recent myocardial infarcts, COPD, asthma and poor exercise tolerance need to be ascertained and further assessed using echocardiography, lung function testing or cardiopulmonary exercise (CPEX) studies.
Surrogate measures of cardiorespiratory fitness include ability to climb stairs, maximum walking distance on a flat surface and ability to sleep lying flat.
Surgical risk
Previous surgery, radiotherapy or localised infections (e.g. peritonitis) can create anatomically hostile operating fields.
Chemotherapy, poor nutrition, steroid use or immunosuppression may lead to poor wound healing and risk of surgical site infections.
High-risk operations will require liaison with ITU specialists regarding high dependency care postoperatively.
Previous deep-vein thromboses, cancers, pregnancy, dehydration and immobility may predispose to future venous thromboembolisms.
Patients with terminal surgical or medical conditions (e.g. metastatic cancer, end-stage respiratory disease) may only be candidates for palliative surgery or conservative management.
Medical risk
The management of a wide range of medical problems requires adjustment in the perioperative period:
Diabetes sufferers may need insulin sliding scales, and may need to be operated on first on the list.
Patients with chronic renal impairment may need dialysis just before and after an operation.
Patients with adrenal insufficiency may require conversion from oral to intravenous steroids.
Patients with pacemakers may need pacemaker checks pre- and postoperatively, as well as the use of bipolar rather than monopolar diathermy intraoperatively.
Patients who are carriers or actively infected with certain organisms (e.g. MRSA, HIV) may require special prophylactic and intraoperative interventions.
Antibiotic or latex allergies need to be identified early in the preoperative assessment, to ensure patient safety during anaesthesia.
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