Any preventive, diagnostic or Any preventive, diagnostic or therapeutic intervention which therapeutic intervention which directly or indirectly disrupts directly or indirectly disrupts

and/or restores the integrity of and/or restores the integrity of the body/organthe body/organ

No single definitNo single definitiion exists!on exists!

DEFINITION OF SURGERYDEFINITION OF SURGERY

Natura Sanat (nature heals)

Proper patientProper patient- adequate indication of surgery(lack of contraindications)- written, informed consent

Proper timingProper timing- wait for the best condition of the patient(depends on the urgency of the case)- preferably operate when the staff is in the best condition

Proper cirProper circcumstancesumstances- all the personal and material conditions of a successful surgery are met – no time constraints

PREREQUISITES OF SURGERYPREREQUISITES OF SURGERY

Theoretical and practical knowledgeTheoretical and practical knowledge- knowledge of the possible treatment options- assessment of the risk/benefit ratio- experience – beyond the learning curve- honor your limits – personal, material, etc.- audition of the results – learn from the mistakes

Knowledge of the patientKnowledge of the patient- history- examination- disease course- think out of the box – are there better non-surgical treatments?

Manual abilitiesManual abilities

THE ROLE OF THE SURGEONTHE ROLE OF THE SURGEON

VitalVitalCan only be treated with immediate/urgent surgery, timing cannot be chosen- major bleeding, ileus, perforation, appendicitis

AbsoluteAbsoluteCan only be treated with surgery, can be scheduled- tumors, symptomatic hernias or gall stones

RelativeRelative May be treated by non-surgical means /no harm done without surgery- asymptomatic hernia or gall stones, GERD

INDICATION OF SURGERYINDICATION OF SURGERY

Social/cosmeticSocial/cosmeticNo harm done without surgery, intervention is peformed upon the request of the patient- breast augmentation, bariatric surgery

ProphylacticProphylacticAims to prevent a later disease or medical condition- FAP, „negative” appendectomy

DiagnosticDiagnostic Aims to diagnose a disease or medical condition- lymph node biopsy, diagnostic laparoscopy

INDICATION OF SURGERYINDICATION OF SURGERY

- To make the decision is at least as important as the surgery itself- To make the decision is at least as important as the surgery itself

- Carefully consider and synthetise all the available data – decision can lead - Carefully consider and synthetise all the available data – decision can lead to death or life-threatto death or life-threatenening compliing compliccationsations

- Sometimes it is easier to operate than - Sometimes it is easier to operate than not to operatenot to operate

- Decision requires adequate knowledge of the disease, the patient, the - Decision requires adequate knowledge of the disease, the patient, the nature of the intervention and the surgeon’s expertise and limitsnature of the intervention and the surgeon’s expertise and limits

- Decision is individual - „- Decision is individual - „me or my relativeme or my relative” test” test

- Decision is not final! Applies only to the given condition of the patient at - Decision is not final! Applies only to the given condition of the patient at the given time in the given institutethe given time in the given institute

INDICATION-CONTRAINDICATIONINDICATION-CONTRAINDICATION

Factors related to the indication of surgeryFactors related to the indication of surgery- Diagnosis- Symptoms (if no exact diagnosis is known)- Timing of the surgery (immediate/urgent/scheduled)- Operative load- Operative tolerance- Operability – technical, medical, oncological- Alternative treatment modalities- Prognosis- Personal/material/(financial) circumstances- Patient consent

ESTABLISHING THE INDICATIONESTABLISHING THE INDICATION

Always consider cost/benefit ratio!

Medical/anesthesiologicalMedical/anesthesiological- Laboratory parameters (ions [K!], blood sugar, Hgb, INR)- Age – decreased significance!- General conditions, co-morbidities- Drugs (e.g. Warfarin, antidepressants)- Allergies, issues with anesthesia/intubation

SurgicalSurgical- Technical (depends on surgeon and institute)- Oncological (curative intent/palliation)

Operability depends onOperability depends on- the nature of intervention- the type of indication

QUESTION OF OPERABILITYQUESTION OF OPERABILITY

Nil Nocere Nil Nocere ((don’t don’t dodo harm harm))!!

Absolute contraindications are lessAbsolute contraindications are less- Most people can be anesthetized and operated- Improved(minimally invasive) operative techniques- Basically there is no contraindication in vital cases!

Contraindication applies to the given patient Contraindication applies to the given patient at the given timeat the given time- Patient’s condition can be improved- Patient’s condition can deteriorate- Can be treated with another treatment modality- Other surgeon, other institute can offer better/alternative methods – „second opinion”

No patient consentNo patient consent- Depends on the age and condition of the patient and the type of indication

CONTRAINDICATION OF SURGERYCONTRAINDICATION OF SURGERY

Absolute contraindicationAbsolute contraindication- Moribund state, coma- Severe cardial failure- Hemorrhagic shock (without surgical cause: e.g. gastrointestinal bleeding)- Severe metabolic or hemostatic imbalance- Lack of written informed consent (except in life-threatening cases)

Relative contraindicationsRelative contraindications- Age- Pregnancy (depends on trimester)- Co-morbidities- Confirmed, end-stage incurable disease- Better alternative treatment modalities- Technical reasons (instruments, staff, circumstances, etc.)

CONTRAINDICATION OF SURGERYCONTRAINDICATION OF SURGERY

Before every surgery: lab tests, chest X-ray, anesthesiologic Before every surgery: lab tests, chest X-ray, anesthesiologic examination + special investigations if necessaryexamination + special investigations if necessary

Score systems to assess the condition of the patient/risk factors - POSSUM, APACHE, RANSOM, ASA, etc.- Only general recommendations, not applicable to every patient- Evidence-based surgery ↔ „the art of surgery”

Assessment of the general condition of the patient- Everyday activity of the patient = cardiorespiratoric reserve, nutrition, diabetes, age (biologic ↔ chronologic), emotional and social conditions

Consultations- Anesthesiology, specialists (cardiology, ECHO, spirometry, etc.)

ASSESSMENT OF SURGICAL RISKASSESSMENT OF SURGICAL RISK

Factors that can be modifiedFactors that can be modified- Diabetes, heart failure (pacemaker)- Blood pressure- Hematologic diseases (history)- Nutritional state (obesity, cachexy)- Infectious sources (teeth, ulcers, etc.)- Certain medication (Warfarin, platelet adhesion inhibitors, tricyclic antidepressants)

Factors that cannot be modifiedFactors that cannot be modifiedAge, sex, chronic diseases

PREPARATION FOR SURGERYPREPARATION FOR SURGERY

Well before the surgeryWell before the surgery

Per os feedingPer os feeding- Nothing per os from the night of the surgery Bowel preparationBowel preparationBlood volume resuscitationBlood volume resuscitationMetabolic balance Metabolic balance - DM, renal functionsAntibioticsAntibioticsThrombosis prophylaxisThrombosis prophylaxis- should be started before the surgeryThorough cleaning (+surgical skin preparation)Thorough cleaning (+surgical skin preparation)Emotional, psychological preparationEmotional, psychological preparation

PREPARATION FOR SURGERYPREPARATION FOR SURGERY

Right before the surgeryRight before the surgery

Unerring surgeon „demigods”, master Unerring surgeon „demigods”, master craftsmen, „above anybody else”craftsmen, „above anybody else”

Intimidated , uninformed patients without Intimidated , uninformed patients without choices and questionschoices and questions

„„Master-slave relationship” Master-slave relationship”

CHANGES DURING THE LAST DECADESCHANGES DURING THE LAST DECADES

Professionally trained, specialized doctors, Professionally trained, specialized doctors, standards and guidelines, evidence-based standards and guidelines, evidence-based surgerysurgeryTreats the patient as partnerTreats the patient as partner

Health-conscious, „educated” patients, who Health-conscious, „educated” patients, who respect the surgeon, but expect the best respect the surgeon, but expect the best available treatment and want choicesavailable treatment and want choices

PRESENTPRESENTororFUTUREFUTURE

PASTPAST

Law conscious patients (and eager Law conscious patients (and eager lawyers)lawyers)- Litigation ↔ defensive medicine (proper documentation) – legal knowledge

No more myth, educated patientsNo more myth, educated patients- Institutes must publish results- Commonly available knowledge (BEWARE the half-educated patient)- Medical-legal advisory homepages, boards

Patient rights offices, specialized Patient rights offices, specialized lawyerslawyers

Financial pressureFinancial pressure- Aging society- High-cost, sophisticated diagnostics- Evidence based surgery – guidelines has to be followed

SOCIAL SETTINGSOCIAL SETTING

PATIENT RIGHTSPATIENT RIGHTS

Right for:Right for:

FOR MEDICAL TREATMENTFOR MEDICAL TREATMENT

FOR HUMAN DIGNITYFOR HUMAN DIGNITY

FOR GETTING ALL INFORMATION RELATEDFOR GETTING ALL INFORMATION RELATED THEMSELVESTHEMSELVES

SELF-DETERMINATIONSELF-DETERMINATION

PATIENT RIGHTSPATIENT RIGHTS

FOR REJECTION ANY KIND OF MEDICALFOR REJECTION ANY KIND OF MEDICAL TREATMENTTREATMENT

FOR MEDICAL SECRECYFOR MEDICAL SECRECY

TO RECOGNISE ALL DATA CREATED DURINGTO RECOGNISE ALL DATA CREATED DURING THEIR TERATMENTTHEIR TERATMENT

FOR HAVING CONTACTFOR HAVING CONTACT PERSONS PERSONS

MALPRACTICE (MALPRACTICE (Who wants to be a millionaire?Who wants to be a millionaire?))

- Around 300 medical malpractice claims annually - Around 300 medical malpractice claims annually in Hungaryin Hungary- - The number is doubled every second yearThe number is doubled every second year- Only 3 out of 10 reaches court stage- Only 3 out of 10 reaches court stage- The amount paid to claimants is 10-fold (average: - The amount paid to claimants is 10-fold (average: 617.000 dollars in 2010 in the USA)617.000 dollars in 2010 in the USA)- Most frequently sued professions: gynecology, Most frequently sued professions: gynecology, surgery, plastic surgery, heart surgery, etc.surgery, plastic surgery, heart surgery, etc.

Most frequent causes:Most frequent causes:- Inadequate communication - Manners- Unwanted results/outcome…- Actual profession mistakes

INFORMED CONSENTINFORMED CONSENT

„…„…right for getting all information”right for getting all information”

Patient counseling, informed consentPatient counseling, informed consent- One of the most common causes of malpractice claims is inadequate counseling- Must be detailed and tailored to the surgery and the patient- The patient has to understand it- Must be signed (also the refusal must be signed)- Interactive (should be signed with the patient)- Not only surgeries (every intervention must be signed by the patient: transfusion, endoscopy, anesthesia, etc.)- Minors and mentally disabled: GUARDIAN- No consent is necessary: vital indication, life-threatening condition, unconscious patient ifdelay may lead to health deterioration

INFORMED CONSENTINFORMED CONSENT

What are the elements of What are the elements of full informed consent?full informed consent?

The most important goal of informed consent is that The most important goal of informed consent is that the patient have an opportunity to be an informed the patient have an opportunity to be an informed participant in his health care decisions. It is participant in his health care decisions. It is generally accepted that complete informed consent generally accepted that complete informed consent includes a discussion of the following elements:includes a discussion of the following elements: -- the nature of the decision/procedure the nature of the decision/procedure -- reasonable alternatives to the proposed reasonable alternatives to the proposed intervention intervention -- the relevant risks, benefits, and uncertainties the relevant risks, benefits, and uncertainties related to each alternative related to each alternative -- assessment of patient understanding the assessment of patient understanding the acceptance of the intervention by the patient acceptance of the intervention by the patient

SALUS AEGROTI SUPREMA LEX!SALUS AEGROTI SUPREMA LEX!