PRE-OP

Question 1

HX

Answer 1

Reassurance: recognize they’re anxious and reassure. Give
overview of the consultation.

History: why they first attended, what procedure they’re
scheduled for (confirm which side).

PMH: CVD (hypertension, exercise tolerance, angina,
orthopnea), respiratory disease (able to lie flat for long
period, chronic cough, obstructive sleep apnea, COPD,
asthma), renal disease, endocrine disease (diabetes
thyroid), GORD, pregnancy, sickle cell disease.

PSH: previous operations (what, when, why), repeat
procedures more lengthy, previous anesthesia (what,
problems, post-op nausea and vomiting).

DH: full drug history (see later notes), allergies (drug and
non-drug).

FH: family problems with anesthesia (malignant
hyperthermia).

SH: smoking, alcohol, recreational drugs, language spoken,
living situation.

Question 2

IX

Answer 2

Bloods: FBC (anaemia or thrombocytopenia), U&E (baseline
renal function for fluids and analgesia), HbA1C, TFTs,
clotting, group and save, ± crossmatch. *If disease.

Cardiac: ECG (major surgery or CVD history), echo (murmur,
ECG changes, S+S of heart failure), BP (<160/100 in
community, no surgery if >180/110 on the day),
cardiopulmonary exercise testing (if major surgery and
chronic disease affecting daily function).

Resp: spirometry (COPD, current baseline).

Other: urinalysis (test for UTI, especially in urology,
pregnancy test), MRSA swab from nostril and perineum (give
decontamination hair and body wash, and nose ointment).

Question 3

advice

Answer 3

Advice: stop eating 6h before, stop clear fluids 2h before. To
ensure stomach is empty, reduces the risk of pulmonary
aspiration (can cause inflammation and infection)

Question 4

anticoagulants

Answer 4

Anticoagulation: warfarin (stop 5d before, INR <1.5, may be
given medications if ≥1.5, if emergency check INR and use
vitamin K, use bridging therapies), heparin (unfractionated
stopped 4h before, LMWH no neuraxial block for 12/24h
prophylactic/treatment dose), rivaroxaban (no neuraxial
block for 18/48h prophylactic/treatment dose), dabigatran
(no neuraxial block for 24h), apixaban (no neuraxial block for
24h

Question 5

antiplatelets

Answer 5

Antiplatelets: clopidogrel stop 7d before, continue aspirin
and NSAIDs

Question 6

antiHTN antiarrhythmics

Answer 6

Antihypertensives and antiarrhythmics: ACE-I stop morning
of major surgery, continue beta-blockers, digoxin do ECG,
digoxin and potassium levels.

Question 7

anticonvulsants

Answer 7

continue

Question 8

diabetic pts

Answer 8

Diabetic: patients put first on list, oral hypoglycemics stop
morning of, if missing >1 meal consider insulin-dextrose
sliding scale peri-op.

Question 9

steroids

Answer 9

Steroids: >5mg OD prednisolone supplement steroids periop (5mg PO prednisolone = 20mg IV hydrocortisone, dose ),
increase dose due to stress response

Question 10

hormonal

Answer 10

Hormonal: OCP and HRT stop 4w before (advise use other
contraception).

Question 11

antidepressants

Answer 11

Antidepressants: MAOi – inform anesthetist (dangerous
interactions with certain anesthetics), lithium (levels, U&E,
TFTs).

Question 12

herbal

Answer 12

Herbal: stop 2w before.

Answer 13

Pre-op medications: analgesics (paracetamol, codeine, ±
NSAIDs), antacids (ranitidine, omeprazole, reduce risk of
aspiration), anxiolytics (midazolam, dependent on
anesthetist), antibiotic prophylaxis (ortho, vascular, GI), TED
stockings (CI: peripheral vascular disease, peripheral
neuropathy, recent skin graft, severe eczema,
lymphoedema), LMWH (not in neck or endocrine, stop 12h
before surgery/give at night, continue for 7d, if major GIsurgery or lower limb joint replacement send home with 28d
prophylactic dose).

Question 14

mobilisation

Answer 14

Mobilization: get up and walking as soon as possible. This
will help with recovery and healing, prevent DVT and
pneumonia. Will have PTOT assessment, may need walking
aids. Good analgesia and pain control.

Question 15

driving

Answer 15

Return to driving: once able to stand up straight and stomp
hard on the ground, practice with pedals when car is
stationary first.
Hip replacement: 6-8w.
Knee replacement: 8w.

Question 16

return to work

Answer 16

Return to non-manual or manual work/activities:
Hernia (small): 1-2w (laparoscopic), 2-3w (open).
Bilateral hernia: 1-2w (laparoscopic), 1-5w (open).
Recurrent hernia: 1-6w (laparoscopic), 1-12w (open).
Large umbilical/incisional hernia: 2-5w (laparoscopic).
Cholecystectomy: 1-3w (laparoscopic), 3-5w (open).
Laparoscopic bowel resection: 2-6w.
Major laparotomy: 6-8w.
Gastrectomy: 6-8w, 8-12w (if malignancy, unlikely to return
to manual work).
Duodenotomy for ulceration: 4-8w.
Appendicectomy: 1-3w, stoma may delay return to work
(normally closed at 3-6m).
Hemicolectomy: 3-10w.
Permanent colostomy: 8-12w.
Hemorrhoidectomy: 2-3w, (full healing 5-6w).
Lung resection: 3-5m.
Renal transplant: 4-8w.
Varicose veins: 2-5d (foam), 1-3w (open).
Total hip replacement: 6w-6m.

Question 17

laparatomy specific complications

Answer 17

LAPAROTOMY
Wound break down (warning sign = pink discharge): burst
abdomen – give IV antibiotics, IVI, analgesia, put viscera back
into abdomen and cover with sterile dressing, return to
theatre; incisional hernia (20%) – mesh insertion repair. Risk
factors: elderly, infection, hematoma, malnourished,
uremia, repeat laparotomy.
Adhesions (90%): difficulty if re-opening (adhesiolysis), can
lead to SBO and chronic pelvic pain.

Question 18

genitourinary surgery complications

Answer 18

Urinoma: rupture of ureter/renal pelvis causes mass of
extravasated urine.
Septicemia: give stat dose of gentamicin.

Question 19

Splenectomy complications

Answer 19

SPLENECTOMY
Thrombocytosis
acute gastric dilation - most use NGT

Question 20

tracheostomy

Answer 20

TRACHEOSTOMY
Early: surgical emphysema, mediastinitis.
Late: stenosis.

Question 21

small bowel surgery

Answer 21

Diarrhoea and malabsorption: vitamin A, D, E, K, B12
deficiencies, bile salt depletion (gallstones), hyperoxaluria
(renal stones).
Short gut syndrome: if <150cm = at risk, support nutrition,
optimize function, correct metabolic abnormalities

Question 22

colonic surgery

Answer 22

Early: ileus, sepsis, fistulae, hemorrhage, anastomotic leak,
trauma to spleen/ureters.
Late: adhesional obstruction.

Question 23

vascular surgery

Answer 23

General: MI, thrombosis, embolism, AV fistula formation,
bleeding, graft infection.
Aortic: respiratory distress, aorto-enteric fistula, renal
failure, gut ischaemia, trauma (ureters, anterior spinal artery
(paraplegia)).

Question 24

mastectomy

Answer 24

Skin necrosis.
Arm lymphoedema (20% if axillary node sampling/
dissection).

Question 25

thyroid surgery

Answer 25

Early: hypoparathyroidism (check calcium daily), thyroid
storm (symptoms of severe hypothyroidism), recurrent
laryngeal nerve palsy (0.5% permanent, 1.5% temporary),
tracheal obstruction due to hematoma (immediately remove
stitches/clips).
Late: hypothyroidism, recurrent hyperthyroidism.

Question 26

biliary surgery

Answer 26

Early: cholangitis, bile leakage, pancreatitis, haemobilia
(melaena, hematemesis), jaundice (?antibiotics, monitor
coagulation, maintain urine output), iatrogenic bile duct
injury, retained stones (ERCP, fistula (chronic bile leakage)).
Late: bile duct stricture, post-cholecystectomy syndrome
(alterations in bile flow due to loss of gallbladder reservoir).