Introduction to surgery

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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CHAPTER 1 Introduction to surgery

The practice of surgery today involves not only technical skills but a whole range of other skills, such as communication skills, delivery of informed consent, breaking bad news and bereavement counselling. Surgical practice must be evidence-based and surgeons must conduct regular audits as well as being aware of their accountability in patient care.

Evidence-based medicine

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. Evidence-based medicine combines the individual doctor’s expertise and the best available external evidence when making decisions about the patient’s healthcare.

Evidence-based medicine is a lifelong process which involves:

Evidence-based medicine has the following advantages:

External evidence includes research from basic medical sciences, patient-centred clinical research, randomized trials and meta-analyses. Patient-centred clinical research looks at the accuracy and appropriateness of diagnostic tests, the use of prognostic indicators and the effectiveness and safety of treatments. External clinical evidence may invalidate previously accepted tests and treatments, replacing them with new ones that are more accurate, effective and safe. Without the current best evidence, surgical practice risks becoming out of date, to the detriment of patient care.

Evidence may be available from individual randomized trials or via meta-analysis of several trials such as those published in the Cochrane Database of Systematic Reviews.

Clinical audit

Clinical audit is a continuous cycle of quality improvement that seeks to improve patient care and service delivery through systematic review of care against explicit criteria and the implementation of change. The clinical audit process is known as the audit cycle. This involves observation of existing practice, the setting of standards, comparison between observed and set standards, implementation of change and re-audit of clinical practice (Fig. 1.1). The main components of the audit cycle are:

Benefits of undertaking clinical audit:

Clinical audit is used to compare current practice with evidence of good practice. It basically asks the question, ‘are we actually doing what we think we are doing?’. Clinical audit can:

When considering topics to audit, the following may be a useful guide; high-risk practice, cost-effectiveness, patient concerns, local concerns, conforming to international guidelines, new treatments or procedures.

Types of audit vary from basic clinical audit, e.g. morbidity/mortality, to national audit, e.g. National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Whatever the subject audited, the following are essential requirements:

How does audit differ from research?

Consent

Informed consent is required for all invasive procedures. Consent should be obtained by the person who is actually going to carry out the procedure or certainly by somebody who is suitably trained and qualified and has sufficient knowledge of the proposed treatment. It is probably best that consent for major procedures is obtained either by the consultant or with the consultant present. It is good practice that consent should be obtained for any procedure that can have a complication.

For consent to be valid, the patient must have the capacity to:

Consent should be informed, i.e. the patient should be given the full information about:

Consent must be voluntary, i.e. not the result of coercion by medical staff, relatives or friends.

Minors between the ages of 16 and 18 are presumed to have capacity to consent in English law. If a doctor feels that a child under 16 has the intelligence and maturity to comprehend the risks and benefits of an intervention (Gillick competence), the patient may consent against parental wishes. Children under 16 who are not Gillick competent may not withhold or give consent; parents must act on their behalf. Patients over 16 with fluctuating capacity (e.g. under the influence of drugs affecting mental state) should be given the opportunity to consent when lucid, if their medical condition can wait until then. Otherwise, doctors may consent on their behalf.

Consent may be verbal or written. Consent forms provide some evidence that the process of consent has taken place, but are not themselves legal documents that prove that consent is valid.

Risks of operation may be general or specific to the operation. The general risks include the risks of anaesthesia and the risks of any operation, e.g. haemorrhage, wound infection, deep vein thrombosis. Examples of specific complications are recurrence after inguinal hernia repair, recurrent laryngeal nerve palsy after thyroid surgery, facial nerve palsy after superficial parotidectomy.

It is generally accepted that complications should be explained to the patient when they arise at a rate of 1% or greater. However, any devastating complication which may occur and has an incidence of less than 1% should be explained to the patient, e.g. paraplegia after aortic cross clamping.

The degree of information to be conferred to a patient continues to evolve through debate in English law. Consent issues challenged by a claimant are tested in English law against the elements of negligence. Rulings have been led by legal precedent. In Sidaway vs. Bethlem Royal Hospital (1985), a patient undergoing cervical cord decompression was not warned against a 1–2% risk of spinal cord injury, which she subsequently suffered. Although she claimed she would not have undergone surgery if she had been warned, a responsible body of surgical opinion would also not have warned a patient of the risk and therefore, the court ruled for the doctor of the basis of the Bolam test.

Since then, in Chester vs. Afshar (2004), surgery for back pain resulted in cauda equina syndrome, the possibility of which the patient was not informed prior to surgery. The judges ruled that failure to inform had violated her right to choose. She may, however, have still opted for this surgery, therefore it is debated that it is difficult to establish causation if the failure to inform may not have changed the outcome, i.e. the patients choice for surgery.

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