Surgical process
This
starts with the patient from whom a careful history is taken. A focused physical
examination is performed, and the complete medical status of the patient
assessed. The likely diagnosis is considered on the basis of this clinical
assessment, and confirmed by the appropriate test. Once confirmed, the
specific treatment, be that medical or surgical, is advised. Should the likely
diagnosis
be wrong, attention is turned to the patient for further details of
their ailment, and a more careful differential diagnosis considered as a basis
for investigation. Continued observation over a limited period of time remains a
powerful tool for achieving a diagnosis.
Despite
current concepts, many patients with complaints requiring surgical treatment
present with a simple history such as a lump or a pain for which a specific
algorithmic approach will provide an answer. Experience will provide an answer
for many patients who present with a physical sign, and no amount of history
taking or examination will add to
that visual assessment. A
sebaceous cyst with its punctum standing proud is a simple surgical condition
requiring a surgical exicision. The patient is operated upon, and the episode
complete. Even the woman who presents with an ulcerating lump on her breast can
be managed similarly in a diagnostic sense, but the knowledge attained in
surgical study warns against a similar simplistic approach, and attention is
turned to confirmation of the diagnosis noninvasively, so enabling full
assessment of the whole patient on the basis of a confirmed pathology, often in
co-operation with colleagues from other disciplines (Fig.
1.3).
Too
little attention has been paid by the surgeon to the ancillary process of
investigation, more so in some disciplines than others. Just as the stethoscope
is helpful in diagnosis, so also ultrasonography, endoscopy and other forms of
imaging will lead to a rapid confirmation of the clinical findings: an
ultrasound scan is done to confirm gallstones (Fig. 1.4), a sigmoidoscopy to
show a rectal carcinoma, a plain radiograph to confirm a fracture (Fig.1.5), magnetic
resonance imaging (MRI) to show a prolapsed disc (Fig. 1.6) and an angiogram to
define the cause of anginal pain. Each has a specific place in the surgical
process, and each makes the operative approach more specific, but none is the
sole reason for operation as the clinical approach dictates that an operation
is only performed for a condition causing symptoms in a patient fit to withstand
the procedure.
Thus,
surgery is about risk assessment. The diagnosis is made, the fitness of the
patient assessed, the procedure determined and the outcome known. Will that
outcome benefit the patient? A tumour in the head of the pancreas, if
left untreated, will kill the
patient in 6 months, so treatment appears mandatory, yet the operation has a
mortality of 10 per cent, the median survival is only extended by
12 months and the comorbid
factors are high, such that many patients will derive little benefit from the
extensive surgery (Fig. 1.7). However, a patient with a strangulated femoral
hernia, which in the elderly patient carries a mortality risk of 10 per cent,
particularly if bowel is resected, faces the same comorbidity risk as the
patient who has pancreatic cancer, but is cured by the procedure, and hence
there is no doubt that the operation is worthwhile and the procedure is
undertaken., At present,
such decisions are matters of judgement, but
with increasing knowledge of risk assessment, the correct procedure or
management can be more easily calculated and fewer errors of judgement made. By
and large, it is errors of judgement that cause surgical misadventure. By
avoiding these errors through better and more exact diagnosis, preoperative
care and postoperative management, the surgical management of patients will
improve. The premortem procedure to prove that everything was done for the
patient that could be done is no longer acceptable, and a more humane approach
to terminal illness is required (Fig. 1.8).