The decision on whether surgery is required has to be made after taking into account all risk factors weighed against the benefits of surgery.
Everyone may have medical conditions that can only be treated by an operation. The operation may be elective or emergency. The latter is performed without delay. The former is scheduled in advance.
There are grades in between, like urgent or semi-elective.
Most surgeries are elective and are planned according to the convenience of both the patient and surgeon. They may extend life, improve the quality of life, or both.
The reasons for surgery may be medical or non-medical. Examples of the former include hysterectomy for uterine fibroids, prostatectomy for prostate cancer, and lens implant for cataracts. Examples of the latter include breast augmentation, face lift and tummy tuck (abdominoplasty).
Although the latter may not be medically indicated, they may improve the quality of life and/or self-esteem.
Emergency surgery has to be done immediately, otherwise, it can result in disability, or even, death. Examples include appendectomy for appendicitis, Caesarean section for foetal distress, and fixation of bone fractures.
The question that every patient has to address is whether the benefits of surgery outweigh the risks, i.e. whether it will improve quality of life.
This is because there is no surgery that is without risk. An understanding of the risks and the benefits will enable better decision-making by the patient. In this regard, a discussion with the surgeon and anaesthetist prior to the surgery will be beneficial.
The risks of any surgery are that of the procedure itself and anaesthesia.
The surgical risks vary with the procedure and whether there are other medical conditions present, e.g. diabetes, high blood pressure, or heart/lung conditions.
There are risks common to all surgical procedures, e.g. bleeding; infection; injury to adjacent organs; blood clot formation in the legs, surgical site or lungs; delayed healing; and swelling and scar formation.
There are also risks specific to the surgical procedure, e.g. paralysis in brain or spinal surgery or nerve injury in thyroid surgery.
The risks of anaesthesia depend on whether general, regional or local anaesthesia is used. Only minor procedures can be done with local anaesthesia. The risks of general anaesthesia vary with the procedure and whether there are other medical conditions present.
The risks include problems with insertion of the tube necessary for breathing (intubation), aspiration of food or fluid into the lungs, as well as awareness during surgery or reaction to drugs given for general anaesthesia.
General anaesthesia for emergency surgery usually has more risks than in elective surgery. The risks of regional anaesthesia depend on the site of the nerve block and includes pain, headache, bleeding, breathing difficulties, infection and nerve damage.
The harm from surgery include operating on the wrong patient; wrong site; bleeding; infection; retained swabs or instruments; allergic reactions and anaesthetic complications; and death.
According to the World Health Organization (WHO), “the reported crude mortality rate after major surgery is 0.5-5%; complications after inpatient operations occur in up to 25% of patients; in industrialised countries, nearly half of all adverse events in hospitalised patients are related to surgical care; at least half of the cases in which surgery led to harm are considered preventable.”
WHO launched its “Safe Surgery Saves Lives campaign” in 2008 with the objective of improving “the safety of surgical care around the world by deﬁning a core set of safety standards that could be applied in all WHO Member states”.
The objectives of the campaign are “the team will operate on the correct patient at the correct site; use methods known to prevent harm from administration of anaesthetics, while protecting the patient from pain; recognise and effectively prepare for life-threatening loss of airway or respiratory function; recognise and effectively prepare for risk of high blood loss; avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk; consistently use methods known to minimise the risk for surgical site infection; prevent inadvertent retention of instruments or sponges in surgical wounds; secure and accurately identify all surgical specimens; and effectively communicate and exchange critical information for the safe conduct of the operation”.
The WHO Safe Surgery guidelines and checklists are used in many Malaysian public and private hospitals.
In order to empower patients, the WHO published its Patient’s Communication Tool for Surgical Safety in 2014.
This tool is recommended to everyone who has been advised to have surgery:
1. Tell doctors about your previous surgeries, anaesthesia and medications, including herbal remedies.
2. Tell doctors if you are pregnant or breastfeeding.
3. Tell doctors about your health conditions (allergies, diabetes, breathing problems, high blood pressure, anxiety, etc).
4. Ask about the expected length of your hospital stay.
5. Ask for personal hygiene instructions.
6. Ask doctors how your pain will be treated.
7. Ask about fluid or food restrictions.
8. Ask what you should avoid doing before surgery.
9. Make sure that the correct site of your surgery is clearly marked on your body.
1. Tell doctors about any bleeding, difficulty breathing, pain, fever, dizziness, vomiting or unexpected reactions.
2. Ask doctors how you can minimise infections.
3. Ask doctors when you can eat food and drink fluids.
4. Ask when you can resume normal activity (e.g. walking, bathing, lifting heavy objects, driving, sexual activity, etc).
5. Ask what, if anything, you should avoid doing after surgery.
6. Ask about the removal of stitches and plasters.
7. Ask about any potential side effects of prescribed medications.
8. Ask when you should come back for a check-up.
Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation that the writer is associated with.