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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_938_Библиотеки_им_академика_М_И_Перельмана
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https://t.me/med1917
13 Fundamentals ofProsthetic Materials
fortheAbdominal Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Udai S. Sibia, Adam S. Weltz, H. Reza Zahiri,
and Igor Belyansky
14 Fundamentals ofBasic Laparoscopic Setup . . . . . . . . . . . . . . . . . 189
Marc Rafols, Navid Ajabshir, and Kr Ben-David
15 Fundamentals ofLaparotomy Closure . . . . . . . . . . . . . . . . . . . . . 207
William W. Hope and Michael J. Rosen
16 Fundamentals ofRobotic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 215
Tomoko Mizota, Victoria G. Dodge, and Dimitrios Stefanidis
17 Fundamentals of Gastrointestinal Anastomoses . . . . . . . . . . . . . 227
Talar Tatarian, Andrew M. Brown, Michael J. Pucci, and
Francesco Palazzo
18 Fundamentals ofVascular Anastomosis . . . . . . . . . . . . . . . . . . . . 239
Selena G. Goss and Dawn M. Salvatore
19 Fundamentals ofExploratory Laparotomy forTrauma . . . . . . . 253
Chia-jung K. Lu and Joshua A. Marks
20 Fundamentals ofTemporary Abdominal Wall Closure . . . . . . . . 265
Shelby Resnick and Niels D. Martin
Contents
21 Fundamentals ofExploratory Thoracotomy forTrauma . . . . . . 275
Deepika Koganti and Alec C. Beekley
22 Fundamentals ofBecoming aSafe andIndependent Surgeon
(From First Assistant toSkilled Educator) . . . . . . . . . . . . . . . . . . 289
Nabeel R. Obeid and Konstantinos Spaniolas
23 Fundamentals ofAcceptable Behavior intheOperating Room
(Etiquette) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Annie P. Ehlers and Andrew S. Wright
24 Fundamentals oftheDaily Routine asaSurgeon: Philosophy,
Mentors, Coaches, andSuccess . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Charles J. Yeo
25 Fundamentals ofManaging theOperative Catastrophe . . . . . . . 321
Idalid Franco, David L. Hepner, William R. Berry,
and Alexander F. Arriaga
Index � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 339
Contributors
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Navid Ajabshir Mount Sinai Medical Center, Comprehensive Cancer
Center, Miami Beach, FL, USA
AllisonA.Aka Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
Alexander F. Arriaga Department of Anesthesiology, Perioperative and
Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital,
Boston, MA, USA
Department of Anesthesiology and Critical Care, University of Pennsylvania
Health System, Philadelphia, PA, USA
AlecC. Beekley Department of Surgery, Division of Acute Care Surgery,
Division of Bariatric Surgery, Sidney Kimmel Medical College at Thomas
Jefferson University, Philadelphia, PA, USA
Igor Belyansky Department of Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
Kr Ben-David Mount Sinai Medical Center, Comprehensive Cancer
Center, Miami Beach, FL, USA
WilliamR.Berry Ariadne Labs, Boston, MA, USA
Center for Surgery and Public Health, Boston, MA, USA
Department of Health Policy and Management, Harvard School of Public
Health, Boston, MA, USA
Andrew M. Brown Department of Surgery, Sidney Kimmel Medical
College, Thomas Jefferson University, Philadelphia, PA, USA
GuillaumeS.Chevrollier Department of Surgery, Sidney Kimmel Medical
College, Thomas Jefferson University, Philadelphia, PA, USA
Karen A. Chojnacki Department of Surgery, Sidney Kimmel Medical
College, Thomas Jefferson University, Philadelphia, PA, USA
DanielJ.Deziel Department of Surgery, Rush University Medical Center,
Chicago, IL, USA
Victoria G. Dodge Department of Surgery, Indiana University School of
Medicine, Indianapolis, IN, USA
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Katerina Dukleska Department of Surgery, Sidney Kimmel Medical
College, Thomas Jefferson University, Philadelphia, PA, USA
AnnieP.Ehlers Department of Surgery, University of Wisconsin, Madison,
WI, USA
RobertD.Fanelli Department of Surgery, The Guthrie Clinic, Sayre, PA,
USA
The Geisinger Commonwealth School of Medicine, Scranton, PA, USA
Albany Medical College, Albany, NY, USA
IdalidFranco Harvard Medical School, Boston, MA, USA
Giulio Giambartolomei The Bariatric and Metabolic Institute, Cleveland
Clinic Florida, Weston, FL, USA
SelenaG.Goss Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
SamuelD.Gross Professor and Chairman, Department of Surgery, Senior
Vice President and Chair, Enterprise Surgery, Jefferson Health, Jefferson
University Hospital, Philadelphia, PA, USA
David L. Hepner Department of Anesthesiology, Perioperative and Pain
Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston,
MA, USA
Ariadne Labs, Boston, MA, USA
Contributors
William W.Hope New Hanover Regional Medical Center, University of
North Carolina at Chapel Hill, Wilmington, NC, USA
FolasadeO.Imeokparia Department of Surgery, The Ohio State University
Wexner Medical Center, Columbus, OH, USA
AdamP.Johnson Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
DeepikaKoganti Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
JessicaA.Latona Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
HarishLavu Jefferson Pancreas, Biliary and Related Cancer Center and the
Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia,
PA, USA
Chia-jungK. Lu Department of Surgery, Division of Acute Care Surgery,
Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia,
PA, USA
Amin Madani Department of Surgery, McGill University, Montreal, QC,
Canada
Contributors
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JoshuaA.Marks Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
Niels D. Martin Trauma and Surgical Critical Care, University of
Pennsylvania, Philadelphia, PA, USA
H.MasonHedberg Department of Surgery, University of Chicago Medicine,
Chicago, IL, USA
NealS.McCall Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
Robin S. McLeod Zane Cohen Centre, Lunenfeld-Tanenbaum Research
Unit, Mount Sinai Hospital, Toronto, ON, Canada
Department of Surgery, The Institute of Health Policy, Management and
Evaluation, University of Toronto, Toronto, ON, Canada
Cancer Care Ontario, Toronto, ON, Canada
Emanuele Lo Menzo Research Institute, The Bariatric and Metabolic
Institute, Cleveland Clinic Florida, Weston, FL, USA
Tomoko Mizota Department of Surgery, Indiana University School of
Medicine, Indianapolis, IN, USA
CarmenL.Mueller Department of Surgery, McGill University, Montreal,
QC, Canada
Kenric Murayama Department of Surgery, John A Burns School of
Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
Nabeel R. Obeid Department of Surgery, Stony Brook Medicine, Stony
Brook, NY, USA
Francesco Palazzo Department of Surgery, Sidney Kimmel Medical
College, Thomas Jefferson University, Philadelphia, PA, USA
Emily A. Pearsall Zane Cohen Centre, Lunenfeld-Tanenbaum Research
Unit, Mount Sinai Hospital, Toronto, ON, Canada
Department of Surgery, The Institute of Health Policy, Management and
Evaluation, University of Toronto, Toronto, ON, Canada
MichaelJ.Pucci Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
MarcRafols Mount Sinai Medical Center, Comprehensive Cancer Center,
Miami Beach, FL, USA
Shelby Resnick Trauma and Surgical Critical Care, University of
Pennsylvania, Philadelphia, PA, USA
ErnestL.Rosato Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
FrancisE.Rosato Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
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MichaelJ.Rosen Cleveland Clinic, Cleveland, OH, USA
Raul Rosenthal Department of Surgery, The Bariatric and Metabolic
Institute, Cleveland Clinic Florida, Weston, FL, USA
Dawn M. Salvatore Department of Surgery, Sidney Kimmel Medical
College, Thomas Jefferson University, Philadelphia, PA, USA
Lawrence A. Shirley Department of Surgery, The Ohio State University
Wexner Medical Center, Columbus, OH, USA
Udai S. Sibia Department of Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
Christina Souther Department of Surgery, John A Burns School of
Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
Konstantinos Spaniolas Department of Surgery, Stony Brook Medicine,
Stony Brook, NY, USA
DimitriosStefanidis Department of Surgery, Indiana University School of
Medicine, Indianapolis, IN, USA
AdamStrickland Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
Contributors
SamuelSzomstein The Bariatric and Metabolic Institute, Cleveland Clinic
Florida, Weston, FL, USA
SamiTannouri Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
Talar Tatarian Department of Surgery, Sidney Kimmel Medical College,
Thomas Jefferson University, Philadelphia, PA, USA
Michael B. Ujiki Department of Surgery, Grainger Center for Innovation
and Simulation, NorthShore University HealthSystem, Evanston, IL, USA
Michael E. Villarreal Department of Surgery, The Ohio State University
Wexner Medical Center, Columbus, OH, USA
Adam S. Weltz Department of Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
Andrew S. Wright Department of Surgery, University of Wisconsin,
Madison, WI, USA
CharlesJ.Yeo Professor and Chairman, Department of Surgery, Senior Vice
President and Chair, Enterprise Surgery, Jefferson Health, Jefferson University
Hospital, Philadelphia, PA, USA
H. Reza Zahiri Department of Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
Fundamentals ofPatient
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Preparation fortheOperating
Room intheTwenty-First Century
EmilyA.Pearsall andRobinS.McLeod
1
1.1 General Concepts
Modern surgery can be performed safely with low
mortality and morbidity rates, even in patients
having complex operations or who have signicant comorbidities. However, to achieve excellent
results, there must be thorough evaluation and
preparation of patients. Even in patients having
emergency surgery, it is important, if possible, to
ensure that patients are in optimal condition. This
requires a full preoperative assessment of their primary condition, as well as their comorbidities. In
addition, patients may require preoperative imaging and appropriate laboratory testing. Depending
on the urgency of their surgery, patients may need
various interventions to optimize their condition.
E. A. Pearsall
Zane Cohen Centre, Lunenfeld-Tanenbaum Research
Unit, Mount Sinai Hospital, Toronto, ON, Canada
Department of Surgery, University of Toronto,
Toronto, ON, Canada
R. S. McLeod (*)
Zane Cohen Centre, Lunenfeld-Tanenbaum Research
Unit, Mount Sinai Hospital, Toronto, ON, Canada
Department of Surgery, University of Toronto,
Toronto, ON, Canada
Institute of Health Policy, Management and
Evaluation, University of Toronto, Toronto,
ON, Canada
Cancer Care Ontario, Toronto, ON, Canada
e-mail: robin.mcleod@cancercare.on.ca
Finally, preoperative education is an important
part of the preoperative work-up.
1.2 Preoperative Assessment
and Care
In all patients, a complete history and examination
is essential. In addition to understanding the presenting condition, it is necessary to know if the
patient has underlying comorbidities and what
medications he/she is on. There are some fairly
common drugs which patients are often taking
such as anticoagulants, steroids, and diabetic medications which may need to be discontinued or modied prior to surgery. As well, diagnostic imaging
should be performed to assist in the planning of the
operation. Finally, it might be worthwhile in some
situations to delay surgery to optimize the patient’s
condition. For instance, patients presenting with an
abdominal abscess who do not require emergency
surgery should have the abscess drained, antibiotics started, and surgery performed on a semi-elective basis. Similarly, in patients presenting with an
obstruction due to a stricture, it might be possible
to decompress the bowel prior to undertaking
surgery.
With respect to imaging and laboratory tests to
prepare patients for surgery, Choosing Wisely has
made a number of specic recommendations for
asymptomatic patients who are undergoing noncardiac low-risk surgery [1]. In these patients, it
© Springer International Publishing AG, part of Springer Nature 2018
F. Palazzo (ed.), Fundamentals of General Surgery, https://doi.org/10.1007/978-3-319-75656-1_1
1
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E. A. Pearsall and R. S. McLeod
is recommended that the following should not be
done routinely but rather selectively utilized:
• Blood count, coagulation testing, and serum
biochemistry tests
• ECG, chest x-ray, ECHO cardiogram, cardiac
stress tests, and pulmonary function tests
• Type and screen for blood
1.2.1 Patient Education
Patient education is an essential component of
preoperative care. Appropriate preoperative education has been shown to decrease patients’ anxiety and fears about surgery, lessen the use of
postoperative analgesia, reduce postoperative
complications, and decrease the length of hospital stay [2–5]. Many patients view surgery as a
threatening experience with many stressful components which elicit strong emotional responses
[4, 5]. These responses can have negative repercussions for the patient in the postoperative
period [3, 4]. Research, although limited, has
shown that preoperative psychosocial interventions also have positive effects on postoperative
psychological and physical functioning [4–6].
With the implementation of enhanced recov-
ery after surgery programs, there is greater
emphasis on self-management and early discharge [6]. This means that patients require more
information about what the expectations of them
are in hospital as well as after discharge, what
they can expect with normal recovery, and nally
how to identify complications and what they
should do if they occur. Patients should receive
this information both verbally and in written format. Ideally, this information should be provided
prior to their preadmission visit to better prepare
them for the appointment and be able to have
questions ready. In addition, patients should be
offered a second appointment with the surgeon
because often they forget to ask questions at their
rst meeting, especially if they received unexpected recommendations. It is also essential that
patients receive a consistent message from all
healthcare providers and standardized messaging
in all written materials. Additionally, patients
should be encouraged to have a family member in
attendance so they are well informed and can
share information with the patient.
1.2.2 Nutritional Evaluation
andSupplements
Malnutrition is a common problem for general
surgery patients, as approximately 14% of elective
GI surgical patients are at risk of malnutrition.
Several studies have shown that patients at risk of
malnutrition often have longer hospital stays as
well as an increased rate of postoperative complications. The European Society for Clinical
Nutrition and Metabolism released a guideline in
2017 on clinical nutrition in surgery [7]. In addition to recommending a shortened fast and carbohydrate drinks up to 2h prior to surgery, they also
recommend that the nutritional status of all patients
should be assessed before and after surgery. The
authors suggest that nutritional therapy, preferable
by the enteral route, should be initiated in patients
who are malnourished or those at nutritional risk.
Additionally, patients who may not be able to eat
or may have a low oral intake prior to surgery may
also benet from nutritional therapy.
A 2012 Cochrane review was undertaken to
review the literature on preoperative nutritional
support in patients undergoing gastrointestinal
surgery. The authors found that immuneenhancing nutrition reduces the risk of complications; however, these studies included
well-nourished surgical patients and excluded
those at high risk of malnutrition. Thus, immuneenhancing nutrition has not been proven to be
benecial for malnourished surgical patients.
Similarly, there was inconclusive evidence to
support preoperative oral supplements and
enteral nutrition. Lastly, parental nutrition
appears to have an effect on total complications
but not on infectious complications in malnourished patients [8].
With regards to nutritional screening, while
the literature strongly recommends that screening
should take place, there is limited information on
the preferred screening method. Both Nutritional
Risk Screening 2002 [see Editors’ Corner at end
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3
of chapter] and Subjective Global Assessment are
most commonly used [9].
1.2.3 Management ofPatients
withDiabetes Mellitus
With the increasing prevalence of obesity, diabetes is seen more frequently in patients having surgery. Depending on the surgical procedure,
approximately 10–15% of patients will be diabetic. These patients are at higher risk for developing complications, having a longer length of
stay, and dying postoperatively. The poorer outcomes may be due to the diabetes or the associated comorbidities.
Patients scheduled for elective surgery should
be seen as soon as the date of surgery is determined
so the patient’s status can be assessed, and if necessary, interventions can be implemented to optimize
the patient when he/she undergoes surgery.
Random glucose levels are of no value and
should not be ordered in patients with diabetes
mellitus. Instead, the patient should have their
HbA1c measured. Generally, individuals with a
HbA1c of less than 69 mmol mol−1 (i.e., 8.5%
NGSP) can be managed with fasting and simple
manipulation of their insulin. On the other hand,
individuals with an elevated HbA1c will likely
require careful monitoring and manipulation of
their treatment. In addition to measuring HbA1c,
diabetic patients should be assessed for comorbidities including ordering of serum electrolytes
and an ECG [10].
Patients with a HbA1c below 69mmolmol
usually can withstand fasting with minor
changes in their insulin requirements or medication. On the other hand, individuals who have a
HbA1c greater than 69mmolmol−1, have poorly
controlled diabetes, are having emergency surgery, or will be unable to take a normal diet after
surgery may require signicant changes to their
care and should be seen by a specialist consultant [10].
For all diabetic patients having surgery, it is
important that there is careful monitoring to
ensure there is normal glycemia and minimal disruption of their usual routine. To accomplish this,
−1
all efforts should be made for these patients to
have a shortened fast, so diabetic patients undergoing elective surgery should be scheduled early
in the day.
1.2.4 Smoking Cessation
Smokers who undergo surgery are at greater risk
for developing pulmonary and surgical-related
complications. This risk may be in the order of a
three- to sixfold increase in intraoperative pulmonary complications [11]. There are a number of
short-term and long-term risks related to smoking. Short-term effects are due to increased concentrations of carbon monoxide and nicotine in
the blood. Carbon monoxide preferentially binds
to hemoglobin over oxygen. Carbon monoxide
also changes the structure of hemoglobin, so
there is a shift in the oxygen hemoglobin curve.
Together, these effects lead to decreased availability of oxygen. Nicotine increases blood pressure, pulse rate, and systemic vascular resistance.
Thus, nicotine increases the work of the heart,
while carbon monoxide decreases the availability
of oxygen. These harmful effects may disappear
after 48h of stopping smoking.
The long-term effects of smoking are related to
atherosclerosis and effects on pulmonary function
including increased mucus which may increase
the likelihood of infection [7]. Lastly, in addition
to the effects on the cardiovascular and respiratory systems, smoking impairs wound healing.
This may affect the surgical wound as well as
increase the risk of anastomotic leaks [11].
A Cochrane Review which was published in
2014 included 13 studies looking at the effect of
preoperative smoking cessation programs [11].
These studies were quite heterogeneous in regards
to their interventions and intensity. The authors
classied them as short and long intensive interventions based on the length of time before surgery they were instituted and the intervention.
Generally, the intensive strategies were started
4–8 weeks before surgery and included weekly
behavioral interventions as well as nicotine
replacement therapy. Both the short and long
intensive programs were effective in decreasing
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E. A. Pearsall and R. S. McLeod
smoking rates, but the results were more favorable
in the long intensive program and were also sustainable. In addition, only intensive programs were
effective in decreasing surgical complications (RR
0.42, 95% CI 0.27–0.65) including wound complications (RR 0.31, 95% CI 0.16–0.62).
The authors concluded that the optimal preoperative intervention intensity remains unclear, but
based on this review, they recommend interventions which are started 4–8weeks before surgery
and provide behavioral support as well as offering nicotine replacement therapy.
1.2.5 Prehabilitation
There is some evidence that there is an association
between patients’ tness before surgery and their
outcomes after surgery including complications,
length of stay, and health-related quality of life
[12, 13]. Several trials assessing whether preoperative exercise programs (“prehabilitation”) have
been performed and have shown mixed results. A
recent systematic review and meta- analysis of
nine studies [13] focusing on abdominal surgeries
found that preoperative exercise was associated
with a 41% decrease in postoperative complications and a 1.6-day reduction in LOS.However,
the studies which were included were of “very
low quality,” due to improper allocation concealment, randomization strategies at high risk of
bias, and biased outcome assessment. There are
also other studies which have not shown a benet
including a study of patients over the age of
60years having colorectal surgery [14].
While there may be some benet to prehabilitation programs, there are some limitations to
their adoption. In particular, these programs may
delay surgery for 4–6 weeks. This may not be
possible, particularly in patients who are having
surgery for a cancer diagnosis where a delay
might not be advantageous or patients who are
receiving other treatments such as neoadjuvant
therapy in that interval.
At the current time, there is insufcient evidence to recommend prehabilitation programs,
but it is an area of interest. Not only may this
increase patient physical well-being but also may
alleviate anxiety and depression and give patients
a sense of empowerment that they can improve
their health.
1.2.6 Blood Conservation
The World Health Organization denes anemia as
an insufcient number of red blood cells (RBC) to
meet physiologic needs [15]. The most common
indicator of anemia is a hemoglobin (Hb) concentration below the normal adult values, with thresholds of 12.0g/dL in women and 13.0g/dL in men
[16]. In the general population, the prevalence of
anemia is generally under 5%, but in the perioperative setting, anemia is more common. An
observational study looking at data from the
National Surgical Quality Improvement Program
(NSQIP) identied 33.9% of 6301 non- cardiac
surgical patients with preoperative anemia [17].
Perioperative anemia appears to be multifactorial.
The most obvious causes can be associated with
the disease for which surgery is required, such as
gastrointestinal bleeding leading to chronic blood
loss, nutritional deciency from decreased oral
intake, or hematologic toxicities from chemotherapy treatments. The anemia of chronic disease
also plays an important role.
Perioperative anemia has been shown to have
negative effects on surgical outcomes. In the
NSQIP analysis, the postoperative infection rate
increased from 2.6% to 5% with increasing
degrees of anemia [17]. Overall, 92% of postoperative infections occurred in anemic patients.
Low preoperative and postoperative hemoglobin
levels were independent risk factors of increased
mortality, postoperative pneumonias, and length
of stay [17]. Furthermore, another meta-analysis
found that allogeneic blood transfusion was signicantly associated with a higher risk of
postoperative infection (OR 3.45, 95% CI 1.43–
15.15) [18].
A number of non-transfusion strategies have
been suggested to correct preoperative anemia
and hopefully lower its consequences. The perioperative use of erythropoietin in colorectal cancer surgery was summarized in a Cochrane
Review in 2009 [19]. Four randomized controlled
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5
trials were included. No difference was observed
in the proportion of patients requiring RBC transfusions. The authors concluded that there was
insufcient evidence to recommend the use of
erythropoietin in colorectal cancer surgery.
The use of perioperative iron supplementation
has been shown to decrease the need for RBC
transfusion either alone or in combination with
erythropoietin or autologous blood donation. In a
randomized controlled trial, 49 patients scheduled for colorectal surgery were randomized to
ferrous sulfate or no supplements for 2 weeks
prior to surgery. Preoperative iron led to higher
hemoglobin and ferritin levels at admission and
decreased likelihood of requiring blood transfusion, along with a 66% cost reduction [20].
Another study compared intravenous iron supplementation, and no difference was observed in
either hemoglobin level at admission or the need
for blood transfusion [21].
In an attempt to reduce transfusion-related
morbidity by limiting the exposure to allogeneic
blood, preoperative autologous donation has
been used. A Cochrane Review included 14 trials. Preoperative autologous blood donation was
associated with a reduction in the relative risk of
receiving allogeneic blood transfusion by 68%
(RR 0.32 [95% CI 0.22–0.47]). However, the risk
of receiving any blood transfusion was increased
(RR 1.24 [95% CI 1.02–1.510). The rate of postoperative infection was not different between
autologous and allogeneic blood transfusion
groups (RR 0.70 [95% CI 0.34–1.43]) [22].
Moreover, preoperative blood donation would
appear to be difcult to use in gastrointestinal
surgery where a signicant proportion of patients
present with anemia.
1.2.7 Mechanical Bowel Preparation
reduces the rates of infectious postoperative
complications such as surgical site infections,
deep intra-abdominal infections, and anastomotic dehiscence. These theories, however,
have been based largely on clinical experience
and expert opinion.
In the recent years, the value for MBP in
patients having elective colonic and rectal surgery has been challenged. MBP is generally safe
but has been associated with serious complications in patients with existing cardiac and renal
disease as well as previously healthy patients.
Furthermore, most patients nd taking a MBP to
be unpleasant. A meta-analysis published by
Slim et al. in 2009 included 14 trials in which
4859 patients were randomized to MBP or no
MBP.The pooled results revealed no signicant
differences in anastomotic leakage rates (OR
1.12, 95% CI [0.824, 1.532], p=0.46) or supercial SSI (9.5% in the MBP group vs. 8.3% in the
no MBP group; OR 1.17, 95% CI [0.96, 1.44],
p=0.11) [
More recently, there has been laboratory evidence that the combination of oral antibiotics and
intravenous antibiotics reduces the risk of anastomotic leaks as well as SSI. The WHO found
moderate quality evidence for prescribing MBP
and oral antibiotics to reduce SSIs in colorectal
surgery [24]. Their systematic review of 11 RCTs
compared MBP with oral antibiotics to MBP
alone and found an OR 0.56 (95% CI 0.37–0.83).
Numerous oral antibiotic regimens have been
studied but usually a combination of an aminoglycoside (neomycin) with erythromycin or metronidazole is prescribed.
Thus, while more evidence is required, it is
possible that MBP with a combination of oral
and intravenous antibiotics may be the preferred
option.
23].
Mechanical bowel preparation (MBP) before
elective colorectal surgery has been the standard in surgical practice for over a century.
Surgeons believed that MBP decreases intraluminal fecal mass and presumably decreases
bacterial load in the bowel. It is argued that a
decrease in fecal load and bacterial contents
1.2.8 Stoma Siting
An ileostomy or colostomy is frequently required
in patients having surgery for benign or malignant indications. The stoma may be permanent or
temporary. Preoperative marking of the stoma is
essential since how well the stoma functions may
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