What are the necessary steps and considerations before and after undergoing surgery?

Preoperative Preparation and Optimization

All patients undergoing elective surgery must receive structured preoperative counseling, risk stratification, medical optimization, and a clear postoperative care plan to minimize morbidity and mortality. 1

Essential Preoperative Steps

Patient Education and Counseling

• Provide dedicated preoperative counseling in oral, written, and pictorial formats to the patient and a caregiver, covering surgical procedures, expected recovery timeline, pain management, early mobilization goals, and discharge planning 1
• This education reduces patient anxiety, postoperative pain, nausea, and improves satisfaction while preparing patients for intermediate-phase recovery that extends into the home setting 1
• Establish discharge plans preoperatively, including emergency contact details and transport arrangements, particularly critical when patients face long travel distances 1

Medical History and Risk Assessment

• Conduct comprehensive assessment focusing on cardiovascular and pulmonary risk factors, functional capacity, and comorbidities 1, 2
• Screen specifically for: smoking status, alcohol use, hypertension, diabetes, anemia, nutritional deficiencies, and delirium risk 1
• In high HIV/AIDS prevalence regions, perform preoperative HIV testing 1
• Obtain 12-lead ECG in all patients with at least one cardiac risk factor or poor exercise tolerance 1

Preoperative Optimization (4-8 Weeks Before Surgery)

Smoking Cessation:

• Mandate complete smoking cessation 4-8 weeks before elective surgery to significantly reduce respiratory and wound-healing complications 3
• Provide face-to-face or telephone counseling with written materials 3
• For urgent cancer surgery, encourage immediate cessation but do not delay necessary procedures 3

Medical Condition Optimization:

• Correct anemia, malnutrition, and deconditioning 1
• Optimize control of diabetes, hypertension, and heart failure 1
• Drain abscesses and treat sepsis before elective procedures 1
• Address nutritional deficiencies identified during assessment 1

Medication Management:

• Discontinue corticosteroids where possible due to increased infection risk 1
• For anti-TNF therapy in Crohn's disease: stop infliximab 6-8 weeks before surgery and adalimumab 4 weeks before if clinically appropriate 1
• Continue thiopurines and methotrexate perioperatively (no increased complication risk) 1
• Do not routinely discontinue aspirin or other cardiac medications unless specifically indicated 1

Fasting and Carbohydrate Loading

• Allow clear fluids until 2 hours before surgery and light meals until 6 hours before 1
• After full meals (meat, fatty foods), require 8 or more hours fasting 1
• Administer 400 ml complex carbohydrate drink (50g CHO) 2 hours before surgery for elective patients 1

Preoperative Testing

• Avoid routine preoperative laboratory testing—order only when indicated by medical history, medications, or procedure type 1
• For patients with severe systemic disease (COPD, poorly controlled hypertension, recent MI, unstable angina, poorly controlled heart failure or diabetes), consider medical evaluation by primary care physician 1
• Obtain chest radiograph in severely obese patients to evaluate baseline pulmonary status and cardiac silhouette 1
• Perform polysomnography if obstructive sleep apnea or hypercapnia suspected 1

Surgical Safety Measures

• Implement WHO surgical safety checklist with all 19 items and three pause points 1
• Administer first-generation cephalosporin within 1 hour of incision; do not continue postoperatively 1
• Provide multimodal PONV prophylaxis (2-3 antiemetics) for high-risk patients 1
• Implement VTE prophylaxis with compression stockings/pneumatic compression plus LMWH or unfractionated heparin 1

Informed Consent

• Obtain informed consent after discussing risks, benefits, expected outcomes, and alternatives to surgery 1
• Document the patient's goals of care clearly in the medical record 1
• For high-risk patients or those with severe life-limiting disease, include senior surgeon, anesthetist, and intensivist in shared decision-making 1
• Assess and document barriers to communication (language, hearing impairment) 1

Postoperative Care Planning

Immediate Postoperative Management

• Resume oral clear fluids as soon as patient is lucid; advance to solids after 4 hours 1
• Mobilize patients 30 minutes on day of surgery, then 6 hours daily thereafter 1
• Continue multimodal opioid-sparing analgesia 1
• Discontinue IV fluids by postoperative day 1 and encourage oral intake 1
• Maintain core temperature ≥36°C throughout perioperative period 1

Follow-up and Monitoring

• Ensure patient and caregiver can attend postoperative visits and address transportation, medication administration challenges preoperatively 1
• For emergency laparotomy or high-risk patients, admit to ICU for minimum 24 hours monitoring as major cardiovascular complications may manifest 1-2 days post-procedure 1
• Conduct multidisciplinary team meetings to review cases where surgery was deemed non-beneficial or patients died without undergoing indicated surgery ("NoLap" patients) 1

Critical Caveats

• Avoid routine mechanical bowel preparation for elective colonic or gynecologic surgery 1
• Do not routinely use nasogastric tubes or drains 1
• Avoid long-acting premedication; consider short-acting anxiolytics only for severe anxiety 1
• For severely obese patients, bariatric surgery is not uniformly low-risk—judicious patient selection and diligent perioperative care are imperative 1
• Risk assessment tools (NELA, POTTER) predict 30-day mortality on population basis; apply to individual patients only as part of overall assessment 1
• Frailty combined with nutritional assessment improves mortality prediction beyond standard risk scores 1