What are the contraindications to surgery?

Contraindications to Surgery

Surgery should be avoided in patients with active infection, recent myocardial infarction (within 3 months), uncontrolled mental illness preventing informed consent, decompensated heart failure, and active bleeding disorders. 1

Absolute Contraindications

The following conditions represent situations where elective surgery must be postponed or avoided entirely:

Cognitive and Psychiatric Barriers

• Patients with drug abuse, alcohol addiction, or uncontrolled mental illness who cannot understand surgical risks, benefits, and consequences should not undergo elective procedures 1
• Unrealistic patient expectations, particularly for procedures like refractive surgery, constitute an absolute contraindication 1

Active Disease States

• Active infection or acute disease events (such as vaso-occlusive crisis or acute chest syndrome in sickle cell disease) preclude any elective, non-urgent procedure 1
• Recent myocardial infarction (less than 3 months) carries mortality rates approaching 90% for elective surgery and represents one of the strongest contraindications 2
• Decompensated heart failure must be stabilized before any surgical intervention 1

Cardiovascular Instability

• Uncontrolled or severe cardiovascular disease that significantly increases perioperative risk 1
• Patients with clinical or electrocardiographic evidence of recent infarction should not undergo elective procedures under any form of anesthesia unless the surgeon accepts extremely high mortality 2

Bleeding and Coagulation Disorders

• Active bleeding is an absolute contraindication 3
• Platelet count <50,000/mL 3
• Severe bleeding diathesis 3

Procedure-Specific Absolute Contraindications

• For metabolic/bariatric surgery: Type 1 diabetes, clear pancreatic β-cell failure, BMI <25 kg/m², and gestational diabetes 1
• For intraocular refractive surgery: active uveitis, uncontrolled autoimmune disease 1

Relative Contraindications

These conditions increase surgical risk substantially but may be acceptable with appropriate optimization and informed consent:

Hepatic Dysfunction

• Significant hepatic dysfunction or cirrhosis increases bleeding risk and impairs wound healing 1
• Advanced liver disease limits the body's ability to metabolize anesthetic agents and synthesize clotting factors 1

Pulmonary Disease

• Pulmonary hypertension increases perioperative mortality risk 1
• Severe chronic obstructive pulmonary disease (COPD) with forced expiratory volume in 1 second <50% of predicted carries increased risk, particularly for procedures >4 hours duration (73% complication rate) or coronary artery bypass grafting (50% mortality) 4
• However, noncardiac surgery in severe COPD patients carries acceptable risk (1% mortality for non-CABG procedures) 4

Limited Life Expectancy

• Major comorbid illness limiting life expectancy to <2 years (advanced malignancy, severe liver disease, severe lung disease) represents a relative contraindication 1
• The risk-benefit calculation shifts when expected survival is limited 1

Cardiovascular Risk Factors

• Old, well-compensated myocardial infarction (>3 months) without dysrhythmia, heart block, or congestive failure carries acceptable risk even for major surgery 2
• Angina, especially with history of infarction, represents intermediate risk 2
• Previous infarction complicated by arrhythmia, A-V block, bundle-branch block, or congestive heart failure places patients in the highest risk category 2

Anticoagulation Issues

• Recent major bleeding as a complication of anticoagulation (intracranial, retroperitoneal, or requiring hospitalization/transfusion) 3
• Heparin-induced thrombocytopenia (platelet count <50,000/mL with or without arterial thrombosis) 3

High-Risk Surgical Situations

• Recent major trauma, surgery, or head injury within 3 weeks 3
• Planned or emergent surgery with high bleeding risk 3
• Elderly patients, those unable to comply with postoperative regimens, and patients with history of falls are at increased risk 3

Ophthalmologic Considerations

• Functional monocularity for procedures with vision risk 1
• Significant eyelid, tear film, or ocular surface abnormalities for ophthalmic procedures 1

Critical Timing Considerations

The 3-month rule for myocardial infarction is paramount: No patient with recent infarction (<3 months) should undergo elective surgery unless the surgeon accepts mortality rates approaching 90% 2. In contrast, patients with old, well-compensated infarction (>3 months) without complications can tolerate even major operations extremely well 2.

Special Population Considerations

Sickle Cell Disease

• Active vaso-occlusive crisis or acute chest syndrome absolutely contraindicates elective surgery 1
• Preoperative transfusion or exchange should be considered based on procedure risk and individual characteristics 1

Diabetes and Metabolic Surgery

• For metabolic surgery in type 2 diabetes, contraindications include BMI <25 kg/m² and gestational diabetes 1
• Only 5.6% of diabetic patients achieve all therapeutic goals for HbA1c, blood pressure, and cholesterol, necessitating careful preoperative cardiovascular assessment 1

Moyamoya Disease

• Recent infarction, infection, or hemorrhage may mandate delays before revascularization surgery 3
• Medical contraindications requiring optimization do not preclude eventual surgery but necessitate appropriate timing 3

Common Pitfalls to Avoid

• Do not assume peptic ulcer disease without bleeding history is an absolute contraindication to surgery 3
• Do not withhold surgery indefinitely in trauma and neurosurgical patients—anticoagulation is typically safe after the first or second postoperative week 3
• Do not assume all stroke patients cannot undergo surgery—most without intracranial hemorrhage can be anticoagulated 3
• Do not extrapolate lower extremity arthroplasty risks directly to shoulder arthroplasty—COPD patients undergoing total shoulder arthroplasty face specific risks of pneumonia (OR 2.793), bleeding requiring transfusion (OR 1.577), and septic shock (OR 9.259) 5