SURGICAL PATHOLOGY

Introduction

PRE-OPERATIVE AND POS-TOPERATIVE CARE

Learning objectives
At the end of this chapter, students are expected to
• Be familiar with pre and post-operative care and complications
• Identify factors which make patients high risk for surgery
• Differentiate postoperative complications
• Manage common post operative complications

Introduction
In the management of patients with surgical procedures, the overall outcome of the
operation mainly depends on the pre-operative diagnosis and the surgical procedure. But in
addition to this, the patient’s pre-operative situation should be well evaluated so as to make the
patient able to withstand the stress of surgery. Factors which make the patient high risk for surgery
should be controlled as much as possible. Also, the patients’ postoperative course highly
depends on the postoperative care given, and anticipation with early diagnosis and management of
postoperative complications.

General consideration

Preoperative evaluation should include a general medical and surgical history, a complete physical
examination and laboratory tests. The most important laboratory tests are:
• Complete blood count
• Blood typing and Rh-factor determination
• Urinalysis
• Chest x-ray
Further laboratory tests should be performed only when indicated by the patients’ medical
condition or by the type of surgery to be performed.

Assessment and Minimization of Surgical Risks

Cardiovascular System

Cardiac problems

The preoperative period is associated with significant cardiovascular stress. Patients with heart
disease should be considered high-risk surgical candidates and must be fully
evaluated.
• Patients with symptoms of previously undiagnosed heart disease (E.g. chest pain, dyspnea,
pretibial edema or orthopnea)
• Recent history of congestive heart failure
• Recent myocardial infarction
• Severe hypertension
• Varicose vein and deep venous thrombosis
Such patients should be evaluated with the assistance of medical or cardiology consultation.

The perioperative monitoring, induction, and maintenance techniques of anesthesia, and

post – operative care can be tailored to the specific cardiovascular diseases.

Pulmonary system

The following respiratory tract problems make patients high risk for surgery;
• Upper airway infections
• Pulmonary infections
• Chronic obstructive pulmonary diseases: chronic bronchitis, emphysema, asthma

Elective surgery should be postponed if acute upper or lower respiratory tract infection is present.
Pulmonary infections also predispose to postoperative bronchitis and pneumonia. If emergency
surgery is necessary in the presence of respiratory tract infection, regional anesthesia should be
used if possible and aggressive measures should be taken to avoid postoperative atelectasis or
pneumonia.

Renal system

Renal function should be appraised

• If there is a history of kidney disease, diabetes mellitus and hypertension
• If the patient is over 60 years of age
• If the routine urinalysis reveals proteinuria, casts or red cells
It may be necessary to further evaluate renal function by measuring creatinine clearance, blood
urea nitrogen and plasma electrolyte determination.

Rheumatologic system

Anemia

Anemia affects the oxygen carrying capacity of the blood, which can complicate the stress of
surgery. Anemia in pre-operative patients is of iron deficiency type caused by inadequate diet,
chronic blood loss or chronic disease. Care must be taken to differentiate iron deficiency anemia
from other anemias. Iron deficiency anemia is the only type of anemia in which stained iron
deposit cannot be identified in the bone marrow. Megaloblastic, hemolytic and aplastic anemia
usually are easily differentiated from iron deficiency anemia on the basis of history and simple
laboratory examinations. Patients with iron deficiency anemia respond to oral or parenteral iron
therapy. In emergency or urgent cases, a preoperative blood transfusion preferably with packed red
cells may be given.

Thrombocytopenia

The normal platelet count ranges from 150,000 to 350,000/ml. In the patient with
thrombocytopenia but normal capillary function, platelet deficiency begins to manifest itself
clinically as the count falls below 100,000/ml. typical manifestations include
• Petechia
• Epistaxis in both sexes and
• Menorhagia in females of reproductive age
• Uncontrolled bleeding which could be intra or post-operative.

Treatment - treat the underlying cause and support with platelet transfusions and clotting factors
as necessary.

Endocrine system

Diabetes mellitus

Diabetics with poor control are especially susceptible to post-operative sepsis. Preoperative
consultation with an internist may be considered to ensure control of diabetes before, during and
after surgery.
In type - II patients, avoid hypoglycemia by closely monitoring blood sugar on the day of
surgery, and possibly by not using the longer acting oral hypoglycemic agents -2 days before
operation. Insulin dependent diabetics with good control should be given half of their total
morning dose as regular insulin on the morning of surgery. This is preceded or immediately
followed by 5% dextrose solution intravenously to prevent hypoglycemia. Regular insulin should
then be given every 6 hrs based on plasma glucose level. Chronic medical conditions associated
with diabetes may also complicate the preoperative period, e.g. Hypertension, myocardial
ischemia which may be silent. These patients should have an extended cardiac work up and
receive metoclopromide as well as a non particulate antacid before surgery.

Thyroid disease

Elective surgery should be postponed when thyroid function is suspected of being either
excessive or inadequate. In Hyperthyroidism, The patient should be rendered euthyroid
before surgery if possible. This may take up to 2 months with anti-thyroid medications.
In hypothyroidism, thyroxin should be started before surgery if possible. In all cases,
treatment should be started with a very low dose of thyroid replacement to avoid sudden and large
workload on the myocardium. The usual tests of thyroid function include T3, T4, and TSH levels.

In addition to the above discussed factors, there are issues which might need special
consideration in preoperative patients. The diagnosis of early pregnancy must be considered in the
decision to do elective major surgery in reproductive age female.
History of serious reactions or sickness after injections, oral administration or other uses of
substances like narcotics, anesthetics, analgesics, sedatives, antitoxins or antisera should be
sought.
The patients’ general hydration status should be assessed and made optimal. Nutritional status of
the patient also needs evaluation and correction.
After all this, prior to the operation, it is important to have an empty stomach because full stomach
can result in reflux of gastric contents and aspiration pneumonitis. In elective surgery, patients
should not eat or drink anything after midnight on the day before surgery.

Post-operative care, complications and their Treatment

Post-operative care

Post-operative care is care given to patients after an operation in order to minimize post
operative complications. Early detection and treatment of post operative complications is possible
if there is optimal care. Some of the care is given to all post operative patients, while the rest are
specific to the type of operation. Routine cares include:

Immediate care:

a. Vital sign checking

b. Chest auscultation
c. Input and output monitoring
d. Checking for bladder and abdominal distention
e. Potent analgesics for pain relief 27

On subsequent post-operative days:

a. Oral intake can be started

b. Patients encouraged to ambulate
In the following sessions, we will focus on common postoperative complications.

Cardiovascular complications

Shock

Postoperative efficiency of circulation depends on blood volume, cardiac function,

neurovascular tone and adrenal secretions. Shock, or failure of the circulation, may follow:

ƒ Excessive blood loss

ƒ Escape of vascular fluid into the extra vascular compartments (“third spacing”)
ƒ Marked peripheral vasodilatations
ƒ Sepsis
ƒ Adrenocortical failure
ƒ Pain or emotional stress
Airway obstruction

Treatment includes
ƒ Arresting hemorrhage
Restore fluid and electrolyte balance
Correct cardiac dysfunction
ƒ Establish adequate ventilation
Maintain vital organ function and avert adrenal cortical failure
Control pain and relief apprehension
Blood transfusion if required.

Thrombophlebitis

Superficial thrombophlebitis

It is usually recognized within the first few days after operation.

Clinical features

A segment of superficial saphenous vein becomes inflamed manifested by:

ƒ Redness ,Localized heat , Swellingƒ,Tenderness

Treatment includes
Warm moist packs
ƒ Elevation of the extremity
Analgesics
Anticoagulants are rarely indicated when only superficial veins are involved.

Thrombophlebitis of the deep veins

Occurs most often in the calf but may also occur in the thigh or pelvis.

Clinical features
It may be asymptomatic or there may be dull ache or frank pain in the affected leg or calf. The
area may be tender and spasm felt in the same area. Examination may reveal slight swelling of the
calf. Dorsiflexion of the foot may elicit pain in the calf (Homan’s sign). Major complication is
pulmonary embolism.

Treatment
• Elevation of the limbs
• Application of full leg gradient pressure elastic hose
• Anticoagulants

Prevention: Early ambulation

Pulmonary embolism
Pre-disposing factors
Pelvic surgery
Sepsis
Obesity
Malignancy and History of pulmonary embolism or deep vein thrombosis
It usually occurs around the seventh to tenth post-operative day. The diagnosis should be
suspected if cardiac or pulmonary symptoms occur abruptly.

Clinical features
Patients with large emboli develop chest pain; severe dyspnea, cyanosis, tachycardia,
hypotension or shock, restlessness and anxiety. In small emboli, the diagnosis is suggested by the
sudden onset of pleuritic chest pain sometimes in association with blood-streaked sputum, and dry
cough may develop. Physical examination may elicit pleural friction rub, but in many cases there
are no classical diagnostic signs. 28

Treatment includes
Warm moist packs
Elevation of the extremity
Analgesics
Anticoagulants are rarely indicated when only superficial veins are involved.

Thrombophlebitis of the deep veins

Occurs most often in the calf but may also occur in the thigh or pelvis.

Clinical features
It may be asymptomatic or there may be dull ache or frank pain in the affected leg or calf. The
area may be tender and spasm felt in the same area. Examination may reveal slight swelling of the
calf. Dorsiflexion of the foot may elicit pain in the calf (Homan’s sign). Major

complication is pulmonary embolism.

Treatment
• Elevation of the limbs
• Application of full leg gradient pressure elastic hose
• Anticoagulants

Prevention: Early ambulation

Pulmonary embolism
Pre-disposing factors
Pelvic surgery
Sepsis
Obesity
Malignancy and
History of pulmonary embolism or deep vein thrombosis

It usually occurs around the seventh to tenth post-operative day. The diagnosis should be
suspected if cardiac or pulmonary symptoms occur abruptly.

Clinical features
Patients with large emboli develop chest pain; severe dyspnea, cyanosis, tachycardia,
hypotension or shock, restlessness and anxiety. In small emboli, the diagnosis is suggested by the
sudden onset of pleuritic chest pain sometimes in association with blood-streaked sputum, and dry
cough may develop. Physical examination may elicit pleural friction rub, but in many cases there
are no classical diagnostic signs.

Investigation
Chest X-ray- findings are pulmonary opacity in the periphery of the affected lung which is
triangular in shape with the base on pleural surface, enlargement of pulmonary artery, small
pleural effusion and elevated diaphragm. ECG may show characteristic changes.

Treatment
Cardiopulmonary resuscitation measures
Treatment of acid-base abnormality
Treatment of shock. Immediate therapy with heparin is indicated even in the absence
of a definitive diagnosis.

Pulmonary Complications

About 30% of deaths that occur within six weeks after operation are due to pulmonary
complication. Atelectasis, pneumonia, pulmonary embolism and respiratory distress
syndrome from aspiration or sepsis, fluid overload or infection are the most common

pulmonary complications.
Atelectasis

Definition

Atelectasis is a pulmonary complication of early postoperative period. It is a condition

characterized by areas of airway collapse distal to an occlusion.

Predisposing factors
Include chronic bronchitis, asthma, smoking and respiratory infection. Inadequate immediate
postoperative deep breathing and delayed ambulation also increase the risk.

Clinical features

ƒ Fever in the immediate post operative period

Increased pulse and respiratory rate
Cyanosis
Shortness of breath
Dull percussion note with absent breath sounds

Investigation

X-ray findings include patchy opacity and evidence of mediastinal shift towards the atelectatic
lung.

Prevention and treatment

Encourage to stop smoking

ƒ Treat chronic lung diseases

Postpone elective surgery in presence of respiratory tract infections
Post operatively, encourage sitting, early ambulation and breathing exercise while
administering analgesics
Intensive chest physical therapy
Supplemental oxygen
Pneumonia and aspiration pneumonitis
Pneumonia may follow atelectasis or aspiration of vomits or other fluids. Preexisting
bronchitis also predisposes to this complication.

Clinical features

ƒ Fever in the first few postoperative days

Respiratory difficulty
Cough becomes productive
Physical examination may reveal evidence of pulmonary consolidation

Investigation

Chest-x-ray may show diffuse patchy infiltrates or lobar consolidation.

Prevention and treatment

Chance of pulmonary aspiration can be minimized by

- Fasting
- Naso-gastric tube decompression
If aspiration of gastric content occurs; an endotracheal tube should be placed and the air way
suctioned and lavaged.

Treatment of pneumonia includes:

ƒ Deep breathing and coughing

Change position frequently to encourage expectoration
Broad spectrum antibiotics therapy should be instituted and revised as indicated by
subsequent sputum culture and sensitivity

Gastrointestinal complication

Paralytic Ileus

It is a functional intestinal obstruction usually noted within the first 48-72 hours 31

Clinical features
Abdominal distention
Absent bowel sounds
Generalized tympanicity on percussion

Investigation

ƒ Plain x-ray-generalized dilatation and gaseous distention of the bowel loops

Treatment

ƒ NGT decompression
Fluid and electrolyte balance

Post operative intestinal obstruction

Causes

ƒ Peritonitis
Peritoneal irritation
Fibrinous adhesion

Clinical features

ƒ Manifests between the 5th and 6th postoperative day

Significant and protracted vomiting
Crampy abdominal pain
Focal typmpanicity of the abdomen on percussion
Exaggerated bowel sounds

Investigation

Plain film of the abdomen usually reveals distension of a portion of small bowel with air fluid
levels.

Treatment

Vigorous hydration and careful electrolyte monitoring is needed. This often results in realignments
of the bowel loops and relief of the obstruction. Patient should be kept NOP and NGT inserted for
decompression. If the obstruction doesn’t respond within 48-72 hours, reoperation is necessary.

URINARY TRACT COMPLICATIONS

Urinary retention

Urinary retention can follow pelvic operations and when spinal anesthesia is used. Inability of the
patient to void is often due to pain caused by using the voluntary muscles to start the urinary
stream. The patient should be encouraged to get out of bed. Bladder drainage by means of a
urethral catheter should be instituted.

Urinary tract infection

Predisposing factors
Pre-existing contamination of the urinary tract
Catheterization

Clinical presentation

• Fever
• Suprapubic or flank tenderness
• Nausea and vomiting

Investigation

-Urine analysis (pus or bacteria will be seen in the urinary sediments)

Nursing management

ƒ Increase hydration
Encourage activity.
After urine specimen is obtained for culture, appropriate antibiotic therapy should be
instituted

Wound complications
Wound infections

Pre disposing factors

ƒ Age
General health
Nutritional status
Personal hygiene habits
Malignancy
Poor surgical technique

Diagnosis: clinical

ƒ Fever during the 4th to 5th day

Redness or indurations at operation site 33

Treatment

ƒ Sutures should be removed

The wound should be explored and cultured
Ample drainage should be established together with local wound care
Appropriate antibiotics if systemic manifestations like fever are persistent.

Hematoma, Abscess and Seromas

These may occur either in the pelvis or under the fascia of abdominal rectus muscle. They are
suspected during falling of hematocrite in association with low-grade fever. Small hematoma or
seroma often resolve spontaneous Ultrasonography is an excellent adjunct to physical
examination. Drainage of infected hematoma should be accomplished extraperitoneally.

Review Questions

1. What are the important components of preoperative patient evaluation?

2. List important laboratory investigations which need to be done in almost all pre-operative

patients despite the specific diagnosis.

3. What are the risks of untreated respiratory tract infection in surgery?

4. Why is diabetes mellitus considered to be pre operative risk?

5. About post-operative shock

a) List the causes, what is the commonest cause?

b) What are the clinical manifestations?.

c) What are the important measures to be taken to combat shock?

6. What is the most common cause of fever in the immediate postoperative period ?

7. Outline the care for an infected post-operative wound.