Introduction

When a patient is admitted for surgical investigation or treatment, a detailed history and examination (clerking) should be done and recorded. These patient notes are essential to make information available to other clinicians and also form a permanent record for medico-legal purposes if things go wrong. Notes must be accurate and legible, entries dated and signed, and the doctor’s name identifiable.

For elective treatment, clerking is often performed at a pre-assessment visit by a junior doctor or a surgical or anaesthetic assistant. This is to anticipate potential medical and social complications, and take preventive action (Box 7.1). In patients with significant co-morbidity, a senior anaesthetist (anaesthesiologist) should also make an assessment. This is often performed in specialised clinics, which increasingly have direct access to advanced assessment tools such as cardiopulmonary exercise testing and pulmonary function analysis.

For emergency admissions, review is often a layered process, with junior doctors performing initial assessment and then reporting to seniors. The prime purpose is to diagnose the primary disorder, but co-morbidity and complicating factors are also sought. For major trauma, senior staff are usually mobilised by phone before the ambulance arrives.

Explanations to the patient and informed consent

(see Ch. 1 for the legal framework, for further detail and special cases)

In order to make informed choices, patients need to understand the nature of their condition and the range of treatments available, with attendant risks and benefits. Patients often absorb little of what is said initially because most have little understanding of how their body works and what can go wrong. They are often anxious and overwhelmed by the clinic visit and so cannot comprehend the full implications.

For elective operations, consent should be in two stages: first an initial explanation and the range of options discussed well in advance, without pressure of an imminent operation. Information leaflets and guidance about accurate internet sites should also be given. Second, before operation, the patient’s understanding is checked and consent confirmed. The doctor should adopt a sympathetic and unhurried approach and often needs to explain things more than once. Informed consent also requires an account of potential complications. Generally, complications should be discussed if there is a 5% or greater risk, or if there are rarer but serious procedure-specific risks such as recurrent laryngeal nerve injury in thyroid surgery.

For emergency surgery, there may not be time to go through this process, nor may it be clear what might be found at operation, but explanations by the surgeon or a surgeon capable of performing the operation should be given as far as possible, and if necessary include close relatives. Patients trust doctors for the most part and seek their guidance on what should be done. The doctor can be unambiguous about best treatment for many conditions but should be prepared to discuss alternatives, even if it means referral to another specialist. Patients tend to be attracted to treatments perceived as modern, often involving ‘keyhole surgery’ or lasers, but a balanced view must be presented, with the doctor understanding the risks and benefits of each procedure.

Planning the recovery period

If the immediate postoperative period is likely to be unpleasant or unfamiliar, such as admission to an intensive care unit, it is prudent to forewarn the patient and arrange a visit beforehand. Patients with learning difficulties and some elderly people have difficulty in adapting to changing circumstances and care should be taken to familiarise them with facilities and staff.

Plans for rehabilitation and convalescence should be discussed with the patient and relatives including the likely rate of recovery and levels of activity possible on discharge, allowing social, business and domestic arrangements to be made early. If necessary, domestic or home nursing help can be arranged. Uncertainty about these matters often causes anxiety and prolongs recovery.

Marking the operation site

When obtaining final consent, the surgeon should mark the operation site on the patient’s skin with an indelible pen. This is particularly important if the operation could be performed on either side of the body, for example an inguinal hernia repair or limb amputation. It is even more important if the patient is likely to be turned prone (face down) in theatre as this causes confusion, and failure to mark the site represents a disaster in waiting (and there is no legal defence). This marking procedure also allows the patient to agree which operation is to be done and on which side. Checking processes for identity, type of operation, side and marking should be in place at several stages during the patient’s journey to the operating theatre and many units have introduced the World Health Organization checklist (see Ch. 1, Box 1.8). Of course, the surgeon needs to be entirely clear what is to be done on the anaesthetised patient presented to him or her!

Immediate preoperative starvation and fluid restriction

Any patient about to undergo general anaesthesia needs an empty stomach to minimise the risk of aspirating gastric contents into the lung on induction of anaesthesia or during early recovery, but efforts should be made to reduce the ‘nil-by-mouth’ period. Patients can usually eat until 6 hours before operation and clear oral fluids should be allowed until 2 hours before surgery. Carbohydrate loading reduces anxiety, improves hydration, reduces insulin resistance and inflammatory responses and improves surgical outcomes. Specially formulated oral fluids containing complex carbohydrates with low osmolality empty rapidly from the stomach and can be given 12 hours before surgery, and up to 2 hours before going to the operating theatre (provided gastric emptying is not impaired). In patients at special risk of inhalation, e.g. gastro-oesophageal reflux, intestinal obstruction, the anaesthetist may prescribe acid suppressing and prokinetic drugs. In day surgery patients, starvation and hydration need to be checked carefully.

Liaison with anaesthetist

For elective cases, the anaesthetist should be informed in advance of the proposed operation or list of operations. For emergency cases, the anaesthetist needs to know which patient is having which operation, how urgent the procedure is, and the condition of the patient and the state of resuscitation. The anaesthetist visits the patient to anticipate problems, discuss the anaesthetic and prescribe premedication. The anaesthetist is responsible for the patient’s fitness for operation and often assists in resuscitation.

Operating theatre arrangements

For any operation, the junior surgeon (intern) is usually responsible for informing the operating department about the operation(s) and any special arrangements needed. A formal operating list should be prepared, giving name, age, sex, ward, and proposed operation for each patient. The side of the body to be operated on should be clearly (and correctly!) noted. Any special instruments, intraoperative radiography or patient positioning must be listed. The presence of meticillin-resistant Staphylococcus aureus (MRSA) infection or a carrier state should be recorded, as well as any important allergies, e.g. to latex or iodine. In some hospitals, the amount of bank blood ordered for a patient is also noted. If changes are made, a complete new list should replace the old to avoid confusion.

Planning the order of an operating list

For elective cases, the following order can normally be recommended:

History

James Brown, a 70-year-old retired farmer, with a proven carcinoma at the rectosigmoid junction admitted electively for anterior resection of the rectum.

Examination

General. Fit-looking man of 70, not obviously anxious. Tanned; not evidently anaemic; no cyanosis, jaundice, lymphadenopathy or clubbing; no thyroid enlargement. Fingers tobacco stained. Not febrile.

Cardiovascular and respiratory system. Pulse 68 beats per minute, regular. BP 150/110 mmHg. Soft systolic murmur at the left sternal edge. No ankle swelling and JVP not elevated. Extensive bilateral varicose veins. Chest examination unremarkable apart from a few crepitations which do not clear with coughing.

Abdomen. Moderately obese. Appendicectomy scar. Soft to palpation. No organomegaly. Possible mass in left iliac fossa—not indentable (i.e. not faeces). No groin hernias. External genitalia normal. Rectal examination—moderately enlarged smooth prostate and normal-coloured stool.

Central nervous system and locomotor system. Fixed flexion deformity of left elbow at 90°, otherwise normal.

Summary

A 70-year-old man with proven rectosigmoid carcinoma without obvious dissemination, admitted for anterior resection of the rectosigmoid.

A problem list was constructed from this information, which led to further investigations and a management plan. The reasoning is shown in Table 7.2.