Major Abdominal Surgery

Question 1

A 65-year-old gentleman is being reviewed in the preoperative anaesthetic clinic prior to admission for a robotic anterior resection for malignancy in 6 weeks. He has a history of hypertension for which he takes captopril and is a smoker. He has previously had surgery for an inguinal hernia.

What do you understand by the term “prehabilitation”?

Answer 1

• An evidenced-based approach targeting high-risk patients, which encompasses medical and lifestyle changes to increase a patient’s physiological reserve preoperatively.
• The goal is to decrease the risk of postoperative complications and enhance the quality of recovery postoperatively, particularly after a major operation.

Question 2

How would you counsel this patient prior to his procedure?

Answer 2

Prehabilitation:
* Enrol the patient onto a local multidisciplinary prehabilitation programme and explain the importance of improvements that can be made; use surgery/malignancy as a “teachable moment” for the patient to make lifestyle changes.

• Explain the importance of nutrition and refer to the dietician if appropriate; the patient may have a poor diet due to malignancy, side effects of medication or pre-existing medical conditions.
• Smoking and alcohol cessation can have a dramatic effect on perioperative risk, and counselling should be offered to the patient for both if appropriate.
• Physical exercise is key preoperatively to increase perioperative physiological reserve.
• Psychologist input may help manage these interventions and offer tools for mood assessment throughout.

Question 3

How would you counsel this patient prior to his procedure?

Continued…?

Answer 3

Risk:
* The risks of major surgery and anaesthesia should be discussed with the patient, including the specific risks associated with particular procedures and the potential postoperative complications and expected recovery timeline.

• Risk stratification can be carried out using a number of different tools to quantify probabilities for the patient but not used as the sole method of explanation.

Perioperative anaesthetic management:
* Options for anaesthesia and analgesia should be discussed with the patient, as well as techniques that may be used to minimise the perioperative risk.

• This includes optimisation of physiological parameters, a multimodal analgesia regimen, early postoperative mobilisation and physiotherapy and senior led care.

Question 4

How can this patient’s risk be quantified preoperatively?

Answer 4

Scoring systems:
* ASA (American Society of Anaesthesiologists).

• Lee’s Revised Cardiac Index (assesses risk of cardiac complications
  afer a non-cardiac procedure).
• POSSUM score (Physiological and Operative Severity Score for the
  enumeration of Mortality and Morbidity).
• SORT (Surgical outcome risk tool).

Functional assessment:
* CPET.

Question 5

How can this patient’s CPET results be used to direct perioperative management?

Answer 5

• Preoperative risk quantification and stratification using an assessment of cardiac and pulmonary function in unison.
• To facilitate shared decision making between the patient and multidisciplinary team.
• To establish a focus for prehabilitation and medical optimisation.
• To allow direction of intraoperative management based on risk.