Surgical Operations

Surgery is an invasive technique with the fundamental principle of physical intervention on organs/organ systems/tissues for diagnostic or therapeutic reasons.

As a general rule, a procedure is considered surgical when it involves cutting of a person's tissues or closure of a previously sustained wound. Other procedures that do not necessarily fall under this rubric, such as angioplasty or endoscopy, may be considered surgery if they involve "common" surgical procedure or settings, such as use of a sterile environment, anesthesia, antiseptic conditions, typical surgical instruments, and suturing or stapling. All forms of surgery are considered invasive procedures; so-called "noninvasive surgery" usually refers to an excision that does not penetrate the structure being excised (e.g. laser ablation of the cornea) or to a radiosurgical procedure (e.g. irradiation of a tumor).

Types of surgery

Surgical procedures are commonly categorized by urgency, type of procedure, body system involved, the degree of invasiveness, and special instrumentation.

Based on timing: Elective surgery is done to correct a non-life-threatening condition, and is carried out at the person's request, subject to the surgeon's and the surgical facility's availability. A semi-elective surgery is one that must be done to avoid permanent disability or death, but can be postponed for a short time. Emergency surgery is surgery which must be done without any delay to prevent death or serious disabilities and/or loss of limbs and functions.

Based on purpose: Exploratory surgery is performed to aid or confirm a diagnosis. Therapeutic surgery treats a previously diagnosed condition. Cosmetic surgery is done to subjectively improve the appearance of an otherwise normal structure.

By type of procedure: Amputation involves cutting off a body part, usually a limb or digit; castration is also an example. Resection is the removal of all of an internal organ or body part, or a key part (lung lobe; liver quadrant) of such an organ or body part that has its own name or code designation. A segmental resection can be of a smaller region of an organ such as a hepatic segment or a bronchopulmonary segment. Excision is the cutting out or removal of only part of an organ, tissue, or other body part from the person. Extirpation is the complete excision or surgical destruction of a body part. Replantation involves reattaching a severed body part. Reconstructive surgery involves reconstruction of an injured, mutilated, or deformed part of the body. Transplant surgery is the replacement of an organ or body part by insertion of another from different human (or animal) into the person undergoing surgery. Removing an organ or body part from a live human or animal for use in transplant is also a type of surgery.

By body part: When surgery is performed on one organ system or structure, it may be classed by the organ, organ system or tissue involved. Examples include cardiac surgery (performed on the heart), gastrointestinal surgery (performed within the digestive tract and its accessory organs), and orthopedic surgery (performed on bones or muscles).

By degree of invasiveness of surgical procedures: Minimally-invasive surgery involves smaller outer incisions to insert miniaturized instruments within a body cavity or structure, as in laparoscopic surgery or angioplasty. By contrast, an open surgical procedure such as a laparotomy requires a large incision to access the area of interest.

By equipment used: Laser surgery involves use of a laser for cutting tissue instead of a scalpel or similar surgical instruments. Microsurgery involves the use of an operating microscope for the surgeon to see small structures. Robotic surgery makes use of a surgical robot, such as the Da Vinci or the ZEUS robotic surgical systems, to control the instrumentation under the direction of the surgeon.

Terminology

List of surgical procedures

Excision surgery names often start with a name for the organ to be excised (cut out) and end in -ectomy.

Procedures involving cutting into an organ or tissue end in -otomy. A surgical procedure cutting through the abdominal wall to gain access to the abdominal cavity is a laparotomy.

Minimally invasive procedures, involving small incisions through which an endoscope is inserted, end in -oscopy. For example, such surgery in the abdominal cavity is called laparoscopy.

Procedures for formation of a permanent or semi-permanent opening called a stoma in the body end in -ostomy.

Reconstruction, plastic or cosmetic surgery of a body part starts with a name for the body part to be reconstructed and ends in -oplasty. Rhino is used as a prefix for "nose", therefore a rhinoplasty is reconstructive or cosmetic surgery for the nose.

Repair of damaged or congenital abnormal structure ends in -rraphy.

Reoperation (return to the operating room) refers to a return to the operating theater after an initial surgery is performed to re-address an aspect of patient care best treated surgically. Reasons for reoperation include persistent bleeding after surgery, development of or persistence of infection.

Description of surgical procedure

Location

Inpatient surgery is performed in a hospital, and the person undergoing surgery stays at least one night in the hospital after the surgery. Outpatient surgery occurs in a hospital outpatient department or freestanding ambulatory surgery center, and the person who had surgery is discharged the same working day. Office surgery occurs in a physician's office, and the person is discharged the same working day.

At a hospital, modern surgery is often performed in an operating theater using surgical instruments, an operating table, and other equipment. The environment and procedures used in surgery are governed by the principles of aseptic technique: the strict separation of "sterile" (free of microorganisms) things from "unsterile" or "contaminated" things. All surgical instruments must be sterilized, and an instrument must be replaced or re-sterilized if it becomes contaminated (i.e. handled in an unsterile manner, or allowed to touch an unsterile surface). Operating room staff must wear sterile attire (scrubs, a scrub cap, a sterile surgical gown, sterile latex or non-latex polymer gloves and a surgical mask), and they must scrub hands and arms with an approved disinfectant agent before each procedure.

Preoperative care

Prior to surgery, the person is given a medical examination, receives certain pre-operative tests, and their physical status is rated. If these results are satisfactory, the person requiring surgery signs a consent form and is given a surgical clearance. If the procedure is expected to result in significant blood loss, an autologousblood donation may be made some weeks prior to surgery. If the surgery involves the digestive system, the person requiring surgery may be instructed to perform a bowel prep by drinking a solution of polyethylene glycol the night before the procedure. People preparing for surgery are also instructed to abstain from food or drink (an NPO order after midnight on the night before the procedure), to minimize the effect of stomach contents on pre-operative medications and reduce the risk of aspiration if the person vomits during or after the procedure.

Some medical systems have a practice of routinely performing chest x-rays before surgery. The premise behind this practice is that the physician might discover some unknown medical condition which would complicate the surgery, and that upon discovering this with the chest x-ray, the physician would adapt the surgery practice accordingly. However, medical specialtyprofessional organizations recommend against routine pre-operative chest x-rays for people who have an unremarkable medical history and presented with a physical exam which did not indicate a chest x-ray. Routine x-ray examination is more likely to result in problems like misdiagnosis, overtreatment, or other negative outcomes than it is to result in a benefit to the person. Likewise, other tests including complete blood count, prothrombin time, partial thromboplastin time, basic metabolic panel, and urinalysis should not be done unless the results of these tests can help evaluate surgical risk.

Staging for surgery
The pre-operative holding area is so important in the surgical phase since here is where most of the family members can see who the staff of the surgery will be, also this area is where the nurses in charge to give information to the family members of the patient. In the pre-operative holding area, the person preparing for surgery changes out of his or her street clothes and is asked to confirm the details of his or her surgery. A set of vital signs are recorded, a peripheral IV line is placed, and pre-operative medications (antibiotics, sedatives, etc.) are given. When the person enters the operating room, the skin surface to be operated on, called the operating field, is cleaned and prepared by applying an antiseptic (ideally chlorhexidine gluconate in alcohol, as this is twice as effective as povidone-iodine at reducing the risk of infection). If hair is present at the surgical site, it is clipped off prior to prep application. The person is assisted by an anesthesiologist or resident to make a specific surgical position, then sterile drapes are used to cover the surgical site or at least a wide area surrounding the operating field; the drapes are clipped to a pair of poles near the head of the bed to form an "ether screen", which separates the anesthetist/anesthesiologist's working area (unsterile) from the surgical site (sterile). 

Anesthesia is administered to prevent pain from an incision, tissue manipulation and suturing. Depending on the kind of operation, anesthesia may be provided locally or as general anesthesia. Spinal anesthesia may be used when the surgical site is too large or deep for a local block, but general anesthesia may not be desirable. With local and spinal anesthesia, the surgical site is anesthetized, but the person can remain conscious or minimally sedated. In contrast, general anesthesia renders the person unconscious and paralyzed during surgery. The person is intubated and is placed on a mechanical ventilator, and anesthesia is produced by a combination of injected and inhaled agents. Choice of surgical method and anesthetic technique aims to reduce the risk of complications, shorten the time needed for recovery and minimise the surgical stress response.

Intraoperative phase

The intraoperative phase begins when the surgery subject is received in the surgical area (such as the operating theater or surgical department), and lasts until the subject is transferred to a recovery area (such as a post-anesthesia care unit).

An incision is made to access the surgical site. Blood vessels may be clamped or cauterized to prevent bleeding, and retractors may be used to expose the site or keep the incision open. The approach to the surgical site may involve several layers of incision and dissection, as in abdominal surgery, where the incision must traverse skin, subcutaneous tissue, three layers of muscle and then the peritoneum. In certain cases, bone may be cut to further access the interior of the body; for example, cutting the skull for brain surgery or cutting the sternum for thoracic (chest) surgery to open up the rib cage. Whilst in surgery aseptic technique is used to prevent infection or further spreading of the disease. The surgeons' and assistants' hands, wrists and forearms are washed thoroughly for at least 4 minutes to prevent germs getting into the operative field, then sterile gloves are placed onto their hands. An antiseptic solution is applied to the area of the person's body that will be operated on. Sterile drapes are placed around the operative site. Surgical masks are worn by the surgical team to avoid germs on droplets of liquid from their mouths and noses from contaminating the operative site.

Work to correct the problem in body then proceeds. This work may involve:

excision – cutting out an organ, tumor, or other tissue.

resection – partial removal of an organ or other bodily structure.

reconnection of organs, tissues, etc., particularly if severed. Resection of organs such as intestines involves reconnection. Internal suturing or stapling may be used. Surgical connection between blood vessels or other tubular or hollow structures such as loops of intestine is called anastomosis.

reduction – the movement or realignment of a body part to its normal position. e.g. Reduction of a broken nose involves the physical manipulation of the bone or cartilage from their displaced state back to their original position to restore normal airflow and aesthetics.

ligation – tying off blood vessels, ducts, or "tubes".

grafts – may be severed pieces of tissue cut from the same (or different) body or flaps of tissue still partly connected to the body but resewn for rearranging or restructuring of the area of the body in question. Although grafting is often used in cosmetic surgery, it is also used in other surgery. Grafts may be taken from one area of the person's body and inserted to another area of the body. An example is bypass surgery, where clogged blood vessels are bypassed with a graft from another part of the body. Alternatively, grafts may be from other persons, cadavers, or animals.

insertion of prosthetic parts when needed. Pins or screws to set and hold bones may be used. Sections of bone may be replaced with prosthetic rods or other parts. Sometimes a plate is inserted to replace a damaged area of skull. Artificial hip replacement has become more common.^[20]Heart pacemakers or valves may be inserted. Many other types of prostheses are used.

creation of a stoma, a permanent or semi-permanent opening in the body

in transplant surgery, the donor organ (taken out of the donor's body) is inserted into the recipient's body and reconnected to the recipient in all necessary ways (blood vessels, ducts, etc.).

arthrodesis – surgical connection of adjacent bones so the bones can grow together into one. Spinal fusion is an example of adjacent vertebrae connected allowing them to grow together into one piece.

modifying the digestive tract in bariatric surgery for weight loss.

repair of a fistula, hernia, or prolapse.

repair according to the ICD-10-PCS, in the Medical and Surgical Section 0, root operation Q, means restoring, to the extent possible, a body part to its normal anatomic structure and function. This definition, repair, is used only when the method used to accomplish the repair is not one of the other root operations. Examples would be colostomy takedown, herniorrhaphy of a hernia, and the surgical suture of a laceration.

other procedures, including:

clearing clogged ducts, blood or other vessels

removal of calculi (stones)

draining of accumulated fluids

debridement – removal of dead, damaged, or diseased tissue

Blood or blood expanders may be administered to compensate for blood lost during surgery. Once the procedure is complete, sutures or staples are used to close the incision. Once the incision is closed, the anesthetic agents are stopped or reversed, and the person is taken off ventilation and extubated (if general anesthesia was administered).

Postoperative care

After completion of surgery, the person is transferred to the post anesthesia care unit and closely monitored. When the person is judged to have recovered from the anesthesia, he/she is either transferred to a surgical ward elsewhere in the hospital or discharged home. During the post-operative period, the person's general function is assessed, the outcome of the procedure is assessed, and the surgical site is checked for signs of infection. There are several risk factors associated with postoperative complications, such as immune deficiency and obesity. Obesity has long been considered a risk factor for adverse post-surgical outcomes. It has been linked to many disorders such as obesity hypoventilation syndrome, atelectasis and pulmonary embolism, adverse cardiovascular effects, and wound healing complications. If removable skin closures are used, they are removed after 7 to 10 days post-operatively, or after healing of the incision is well under way.

It is not uncommon for surgical drains to be required to remove blood or fluid from the surgical wound during recovery. Mostly these drains stay in until the volume tapers off, then they are removed. These drains can become clogged, leading to abscess.

Postoperative therapy may include adjuvant treatment such as chemotherapy, radiation therapy, or administration of medication such as anti-rejection medication for transplants. For postoperative nausea and vomiting (PONV), solutions like saline, water, controlled breathing placebo and aromatherapy can be used in addition to medication. Other follow-up studies or rehabilitation may be prescribed during and after the recovery period. A recent post-operative care philosophy has been early ambulation. Ambulation is getting the patient moving around. This can be as simple as sitting up or even walking around. The goal is to get the patient moving as early as possible. It has been found to shorten the patient's length of stay. Length of stay is the amount of time a patient spends in the hospital after surgery before they are discharged. In a recent study done with lumbar decompressions, the patient's length of stay was decreased by 1–3 days.

The use of topical antibiotics on surgical wounds to reduce infection rates has been questioned. Antibiotic ointments are likely to irritate the skin, slow healing, and could increase risk of developing contact dermatitis and antibiotic resistance. It has also been suggested that topical antibiotics should only be used when a person shows signs of infection and not as a preventative. A systematic review published by Cochrane (organisation) in 2016, though, concluded that topical antibiotics applied over certain types of surgical wounds reduce the risk of surgical site infections, when compared to no treatment or use of antiseptics. The review also did not find conclusive evidence to suggest that topical antibiotics increased the risk of local skin reactions or antibiotic resistance.

Through a retrospective analysis of national administrative data, the association between mortality and day of elective surgical procedure suggests a higher risk in procedures carried out later in the working week and on weekends. The odds of death were 44% and 82% higher respectively when comparing procedures on a Friday to a weekend procedure. This "weekday effect" has been postulated to be from several factors including poorer availability of services on a weekend, and also, decrease number and level of experience over a weekend.

Postoperative pain affects an estimated 80% of people who underwent surgery. While pain is expected after surgery, there is growing evidence that pain may be inadequately treated in many people in the acute period immediately after surgery. It has been reported that incidence of inadequately controlled pain after surgery ranged from 25.1% to 78.4% across all surgical disciplines. There is insufficient evidence to determine if giving opioid pain medication pre-emptively (before surgery) reduces postoperative pain the amount of medication needed after surgery.

Postoperative recovery has been defined as an energy‐requiring process to decrease physical symptoms, reach a level of emotional well‐being, regain functions, and re‐establish activities. Moreover, it has been identified that patients who have undergone surgery are often not fully recovered on discharge.