Surgery - Preparation and Recovery
The Operation Itself
In the past, surgery almost always involved large incisions, heavy anesthesia, and relatively long procedures. But with modern advances, surgical procedures have become safer, quicker, and less invasive, allowing patients to recover more quickly.
Types of Surgery
In recent years, surgeons have found many ways to make surgery less invasive. Traditional surgery, where the skin and underlying tissues are cut through with a scalpel, is called open surgery. Recovery after open surgery is generally longer than recovery after less invasive procedures, and patients are more likely to have complications during recovery (Fan 2018). While in the past open surgery used to be the only option for some surgical interventions, in recent years it has been increasingly replaced by minimally invasive surgery (Langer 2016; Doenst 2017; Stanford Health Care 2017b; Salem 2018; Sood 2015).
When the medical issue can be addressed without open surgery, surgeons use a less invasive technique such as a laparoscopic procedure (Mayo Clinic 2017). Laparoscopic surgery is a type of minimally invasive surgery that uses smaller incisions (Nezhat 1992; Ross 2009). A long, thin instrument called a laparoscope is inserted into a small hole to allow the surgeon to see the target area (Stanford Health Care 2017a). Additional instruments are inserted through the same or other small incisions. Patients having minimally invasive surgeries, such as laparoscopic surgery, lose less blood, have fewer infections, and go home sooner than patients having open surgery (Wang 2017; Xiong 2017; Huang 2013).
Laparoscopic surgery is commonly performed to correct problems in the abdomen, but surgeries in other parts of the body have also become less invasive with the help of imaging. Video-assisted thoracoscopic surgery procedures use a tiny camera inserted through small incisions to guide surgeries in the chest area (Xu 2013; Dziedzic 2015). Computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) can all be used in image-guided surgeries to help surgeons carefully target the intended area and avoid healthy surrounding tissues (Tringale 2018; Jenkinson 2018; Stammes 2018).
Doctors can perform some surgeries with the help of robots (Mayo Clinic 2018b). Robotic surgery requires only tiny incisions and can help the surgeon control the instruments with more precision (Peters 2018). Robotic procedures may lead to less blood loss (Ilic 2017) and fewer complications (Kim 2018; Barrie 2016).
Lasers are a valuable tool for some surgical procedures. Lasers create a concentrated beam of energy that can cut through some types of tissue (Stanford Health Care 2017b). Surgeries on delicate tissues and organs, such as the eyes, can use lasers instead of traditional cutting tools. Lasers can also be used to directly repair some problems. For instance, lasers can be used to remove plaque from an artery, repair gums, or treat small stomach tumors (Sobouti 2015; Azadgoli 2016; Livesay 1984).
More extensive surgical procedures may require the patient to stay one or more nights in the hospital (Stanford Health Care 2017e). These are called inpatient surgeries. With modern advances, procedures have become far less invasive and recovery from anesthesia is quicker. More patients can go home the same day as the surgery (Stanford Health Care 2017c). These are called outpatient or ambulatory surgeries.
Types of Anesthesia
The type of anesthesia required will depend in part on the type of surgery the patient is undergoing. A surgery affecting a small area of the body, particularly on or near the skin, may require only local anesthesia (Stanford Health Care 2017h; Mutalik 2008; Skidmore 1996). The patient is numbed in only a small area, and over time the anesthetic wears off.
For some procedures affecting larger parts of the body, anesthesiologists may be able to target the nerves from the area undergoing surgery (Stanford Health Care 2017h; Wahal 2018). This is called regional anesthesia. Regional anesthesia is often used for surgeries on the arms and legs, Caesarean section, and certain procedures in the bladder or urinary tract (ASRA 2018).
Patients can remain awake with regional anesthesia, but a sedative may also be used to keep the patient comfortable (ASRA 2018). Sedation can range from minimal to deep. Because sedatives can slow the patient's breathing, an anesthesiologist monitors the patient's vital signs carefully to avoid any complications.
Under general anesthesia, the patient is unconscious throughout the procedure (Stanford Health Care 2017h). The anesthesia affects the whole body. After the procedure, the patient wakes up in the recovery room with no memory of the procedure.
Although complications with anesthesia can be severe, they have become rare with advances in anesthesia practices (Botney 2008; Schnittker 2015). Anesthesiologists plan the array of medications carefully to minimize negative effects. They also carefully monitor their patient's blood pressure, heart rate, and blood oxygen levels throughout the surgery (Merry 2010). With sedation or general anesthesia, proper breathing may be maintained with oxygen, lung ventilation, and breathing tubes.
Table 1: Types of Anesthesia
|Type of Anesthesia||
Surgical techniques have been improved to try to reduce the need for blood transfusions (Carabini 2018; Stoneham 2017). If the medical team believes a patient may need a blood transfusion during an upcoming surgery, the patient may donate blood ahead of time so their own blood will be available during the procedure (Boer 2018). This is called an autologous transfusion. Blood transfusions have been associated with many complications, including an increased risk of heart rhythm problems (Liu 2018) and kidney failure (Paone 2014) in patients undergoing heart surgery and a higher risk of postoperative death (Lee 2018; Crawford 2018). Massive blood transfusions can have untoward effects, especially with regard to calcium status (Giancarelli 2016).
The oxygen provided during surgery may itself be a mixed blessing. A sufficient supply of oxygen to the surgical site is critical for maintaining normal cellular processes and for proper wound healing. However, supplemental oxygen, when used at high concentrations, may also produce increased levels of reactive oxygen species, which may cause harmful inflammation and can damage tissues (Francis 2017; Martin 2015; Dikmen 2017). Although an inflammatory response is necessary during the first stages of healing, sometimes when it becomes accentuated after surgery, as a result of depressed immunity, it may lead to complications such as infections (Angele 2005).
During cardiac bypass surgery and some other surgeries, blood flow to the area where the surgery is performed is restricted with surgical clamps. When the clamps are removed, blood flows into the surgical area again. Studies have shown that if the blood oxygen level is too high when the clamps are removed, the tissue can be damaged (Inoue 2002; Sepehrvand 2016). Also, patients with high oxygen levels (hyperoxia) are at an increased risk for needing mechanical ventilation and acquiring an infection (Jakutis 2017).
Prevention of Blood Clots
Deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein, typically in the leg (Mayo Clinic 2018a). Blood cannot exit the limb properly, and the limb may start to swell. If the clot or pieces of it break free, they can travel through the bloodstream to the lungs, where the effects are more dangerous (Sogaard 2014).
Surgical patients are at increased risk of DVT due to medications given during surgery, lack of mobility for hours or days or, sometimes, underlying medical conditions (Osaki 2017; Aibinder 2018). During surgery, compression stockings or devices that fill with air to compress the lower legs may help patients at risk for DVT (Bell 2015; Sederino 2016; Elbuluk 2018).
During a surgical procedure, there are several medical professionals in the operating room. The surgeon performs the surgery, typically assisted by one or more registered nurses that specialize in surgery (Stanford Health Care 2017i). The anesthesiologist is responsible for the anesthesia plan and monitors the “ABCs,” or airway, breathing, and circulation, during surgery (Becker 2007). A certified registered nurse anesthetist will often assist the anesthesiologist. Surgical technicians may carry out various duties before, during, and after the operation to assist the rest of the operating staff and patient.