Phases of the surgical procedure

Published on 08/03/2015 by admin

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Last modified 08/03/2015

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CHAPTER 2 Phases of the surgical procedure

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Diagnosis

The first step in the proper performance of surgery is correct diagnosis. The significance of this simple sentence is – sadly – inadequately appreciated. ‘Diagnosis’ involves far more than merely assigning a generic heading such as ‘cataract’.

Correct diagnosis demands adequate evaluation of the patient as a person biologically and psychologically. For example, a proper surgical decision for the patient with early glaucoma requires far more than isolated evaluation of the discs and the fields; in the patient with exophthalmos, far more than mere delineation of the most probable causes for forward displacement of the globe; and in the patient with a retinal detachment, far more than examination of the peripheral fundus. If preoperative evaluations do not provide the surgeon with the necessary information to make appropriate decisions, optimal results will not be achieved.

Resources and facilities vary widely from place to place. There may be circumstances in which it is not feasible to obtain the most sensitive diagnostic examinations possible for a particular patient. In the rare instances where this is the case, the surgeon must remember the shortcomings of the examination and must not credit the data with false validity.

In the overwhelming majority of cases, however, it is possible to gather enough valid information to arrive at a reasonably sure diagnosis. Appropriate efforts should be made. A common cause of an unsatisfactory surgical result is an inadequate evaluation of the patient, and consequent inaccurate diagnosis. Still, costs and time are relevant issues. Preoperative studies should be limited to those that are relevant.

Preparation of the patient

The surgeon must adequately prepare the patient, and in some instances the patient’s family, for any proposed surgery.

There are two quite different aspects of this preparation: (i) physical, and (ii) mental/emotional.

Physical

Aspects of the patient’s health, including use of medications that will impact the surgical episode, must be known by the operating surgeon. In order to assure that these are understood and that information is not overlooked, detailed written procedure forms are advisable. For example, asking patients if they are taking aspirin may result in false negatives simply because patients are unaware that one of their medications contains aspirin. Therefore, they need to be asked, ‘Are you taking any of the following medications?’ and then be provided with a list of medications that contain aspirin (Appendix 1). These queries are often best understood and answered when written, so the patient can gather needed information and assemble necessary medical records.

Detailed instructions about what is needed prior to the surgery should be provided, including suggested changes in medications, with clearly stated dates and times when such changes are to be made (Appendix 2). Insurance considerations are often complex and must be addressed.

It is essential that postoperative plans be made and understood preoperatively: time and place for follow-up visits, contact information, likely postoperative medications and limitations on activity (Appendix 3). Also, it is important for the patient and the operating surgeon to know who will be in charge of the postoperative care. Ideally, this should be the operating surgeon. When this is not possible, the patient must know that fact preoperatively and be agreeable to the suggested plans.

It is highly preferable to have a single person dedicated to coordinating the entire surgical episode. Such a person, the surgical coordinator, should be highly conscientious, available to patients, knowledgeable and compassionate.

Mental/emotional aspects

Blindness is not only incapacitating but is also disabling to the spirit. The thought of eye surgery is thus deeply threatening for most individuals. It is the ophthalmologist’s duty, therefore, to explain tactfully to patients the nature of their problem and to mention the available options for managing it. Such a discussion should include the possibility of treatment by non-surgical means, the nature of surgical options (with attention toward reasonable prognosis), the effect the surgery would probably have on the patient’s life style, the probability of partial or total disability, and the anticipated costs. They should also include a discussion of what is likely to happen in the absence of surgery. If the surgeon cannot in good faith and to a high degree of certainty provide such information, surgery is not justified. Figure 2.1 provides a graphic representation of this idea, a concept which is important both to the patient and to the surgeon.

The surgeon should remember that a surgical procedure can be considered a violation of a patient’s privacy. The patient should make the ultimate decision as to whether or not surgery is to be performed and by whom. It is the doctor’s responsibility to advise the patient that he or she has a condition requiring surgery, to offer the possibility of a surgical correction, and to provide enough information to permit the patient to make an appropriate decision. The information should be presented in a clear-cut, reassuring manner, so that the patient will not automatically reject the idea of necessary surgery. The risks of performing surgery should be explained, but always in a format in which they are weighed against the risks of not performing surgery. It is a mistake to tell a patient that he has an X percent chance of losing sight in surgery, without also telling him that he has about a Y percent chance of losing sight if the surgery is not performed. When such comparative risks are explained, the patient is usually inclined to make a decision in line with the surgeon’s own opinion.

In some cases a patient is reluctant to make the surgical decision himself and asks the doctor to take on this burden. Though patients should be encouraged to participate in deciding upon which option is most appropriate, when the patient chooses not to do so, it is not only the doctor’s right but also his obligation to make what he or she judges to be the most reasonable decision.

When a patient differs in his conclusion from that of the surgeon, it is quite possible that it manifests from a lack of confidence in the surgeon. In such instances surgeons may wish to ask the patient if a consultation is desired. Surgeons should not wait for the patient to request such a consultation, for patients are frequently reluctant to do so. If the patient is sent to a second surgeon, the patient and the second surgeon should ordinarily be told that if the patient wants the surgery done by the second surgeon, the second surgeon should feel free to do it.

Other reasons patients may not concur with a recommendation for surgery are important to consider and address. Some patients have performed extensive research on their condition and their potential surgery. They may have even been led to believe that an alternative procedure is preferable, for example. In case of fact, these patients are sometimes correct. Surgeons do not always know what is the best treatment for a patient. They may not advise the most appropriate procedure. For example, they may not have thought of it, they may not know how to perform it, or their experience with it may have been selectively and inappropriately poor. Some patients do not wish their surgery to be performed by elderly doctors, and some do not wish their surgery to be performed by doctors they consider young and inexperienced. Patients may be reluctant to make such a comment. Surgeons should be very sensitive to any appearance that patients are concerned about moving ahead with surgery. The results are too unpredictable; therefore it is both in the patient’s and the surgeon’s best interest to make sure that patients truly want to have their surgery performed. It is essential that the prospective surgeon listen attentively and not become defensive.

Issues of convenience and cost are real, and may also be reasons why patients prefer either to avoid surgery entirely or perhaps to have it performed in a different site. These matters need to be addressed.

A variety of forms can be utilized to help provide the patient with the necessary information regarding his diagnosis, hospitalization, and recovery (Appendix 3). While brochures prepared by professional firms and various agencies are available, it is a relatively simple thing for surgeons to prepare such forms themselves. The forms are then more likely to be fully pertinent. Such information, however, should never be considered a substitute for direct communication between the patient and the surgeon. While patients do, to varying degrees, want to know technical and practical details, what they must know without doubt is that they trust their surgeon. That trust is the consequence of the patient having an unwavering belief that the surgeon unquestionably intends to be of benefit to the patient. The patient knows that if such sincere intent is present, the surgeon will require himself or herself to act competently. When the provision of brochures, or discussions with paramedical personnel, lead the patients to feel that those brochures or discussions are primarily to save the surgeon time and to avoid personal responsibility, they actually decrease the patient’s trust.

Informed consent or informed choice

‘Informed consent’ involves important medical and ethical considerations as well as the more strictly legal ones1. The following discussion will deal primarily with the ethical aspects of informed consent, with the meaning of the phrase, and with its importance for the patient, the physician, and the medical profession2,3,4.

Informed consent is in many ways at the heart of all good systems of medical and surgical practice. It essentially means that the patient appropriately understands the risks and the benefits involved in a proposed procedure. Such understanding demands knowledge and discussion. It also requires a two-way contract between the patient and the surgeon. The enhancement of such knowledge, such discussion, and such contracts may be the best way to ensure high quality medical care.

In the Commonwealth of Pennsylvania informed consent is defined as ‘the consent of a patient to the performance of health care services by a physician or a podiatrist, provided: that prior to the consent having been given, the physician or podiatrist has informed the patient of the nature of the proposed procedure or treatment and of those risks and alternatives to treatment of diagnosis that a reasonable patient would consider material to the decision whether or not to undergo treatment or diagnosis.’

Exceptions to the rule exist, and the law states that physicians will not be held liable for failing to obtain informed consent in the following circumstances:

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