HOW SURGICAL OPERATION IS DONE

How surgical operation is done

by Dr. Tajuddin FCPS FRCS

Assistant Professor of Surgery

Baqai Medical University karachi pakistan

Pre-operative preparation

1. Consent: All patients should give informed consent for all procedures.

2. Rehydration: In emergency cases do not forget the need for rehydration by an intravenous infusion to correct any electrolyte disturbance, particularly if the patient has been vomiting.

3. Nasogastric tube: A nasogastric tube (e.g. a 15F oesophageal tube with side holes) is essential preoperatively if the patient is obstructed, as any vomiting on induction may lead to inhalation problems.

4. Urinary catheter: For any lower abdominal or pelvic surgery, an empty bladder is necessary. A catheter (e.g. a 16F Foley catheter) is also essential for any sick or shocked patient undergoing major surgery in order to monitor their intraoperative urinary output.

5. Cross matched blood: There is a tendency to over-cross match blood for surgery, but certain procedures require that blood should be immediately available, while other procedures merely require that the patient's serum is grouped and saved.

6. Premedication: This is usually left to the anaesthetist to prescribe, but it is wise to be aware of those agents in common current use. No premedication is given in the case of neurosurgery for head injuries, or for any unconscious patient.

7. Starved: If general anaesthesia is employed, patients should be starved for at least 4 hours.

8. Marking: All unilateral lesions or limbs that are to be subjected to surgery should be clearly marked with an indelible pen. Varicose veins are another example where the surgeon himself should mark the lesions pre-operatively with the patient standing up. Stoma siting pre-operatively is strongly recommended.

9. Shaving: This is a debatable point. Most surgeons like to work in a pre-operatively shaved field, although others feel that this is counterproductive and may actually increase the incidence of wound infections.

10 Prophylaxis

• Antibiotics:

— There is now strong evidence that antibiotic prophylaxis plays a major role in preventing postoperative sepsis. This is particularly the case when implants are used, e.g. vascular surgery, insertion of orthopaedic prostheses, cardiac valve replacements, mammary prostheses, etc.

— It is also advisable to use such prophylaxis when endogenous contamination is high, e.g. gastrointestinal, biliary and colorectal surgery.

— Current policy tends to indicate the use of a broad- spectrum cephalosporin in most instances, with the
addition of an anti-anaerobic agent like metronidazole, when the large bowel is involved. Such regimens are
inevitably tailored to the patient's needs, and should be started pre-operatively at induction of anaesthesia
• Antithrombotic precautions: Most surgeons use these routinely, while others tend to reserve them for high-risk cases, e.g. elderly, obese, on the pill, previous thrombotic episodes, malignancy, polycythaemia, etc.

11. Special requirements

• Steroids: Patients on long-term steroid therapy are in a state of adrenal cortical suppression, and therefore will require. extra replacement steroids to cover the extra needs of surgery: 100-200 mg of hydrocortisone pre-operatively, continued postoperatively at a dose regimen dependent on the previous steroid dosage.

• Jaundice

— A jaundiced patient may well have defective clotting abilities and therefore will require vitamin K parenterally to correct this (10 mg vitamin k] daily, preferably intravenously, to minimize the risk of intramuscular haematoma formation).

— An adequate urinary output during induction and surgery is necessary, and therefore satisfactory hydration during the peri-operative period is essential. Some surgeons use a 40-50 g mannitol infusion to induce a peri-operative diuresis in an attempt to prevent renal failure. A pre-operative infusion of low-dose dopamine may protect the kidneys.

• Diabetes: Diabetic patients will require special care in monitoring the glucose level, especially in the emergency situation. Wherever possible diabetic patients should be placed first on the operating list. A possible management protocol may be:

Diet controlled

— no specific action required

— If hyperglycaemia occurs then a sliding scale of insulin should be used, or a glucose-potassium-insulin infusion
Oral hypoglycaemics

— omit agents on day of surgery

— long-acting agents should be stopped the day before surgery (e.g. chlorpropamide)

— monitor blood glucose in peri- and postoperative period.
If hyperglycaemia occurs consider sliding scale or glucose-potassium-insulin infusion

— resume hypoglycaemic agents on return to full enteral diet
Insulin dependence

— omit morning dose of insulin

— if prompt return to enteral feeding anticipated then consider glucose-potassium-insulin infusion

— if delayed return to enteral feeding then start sliding scale insulin infusion

Sliding scale

— the dose used should be related to the degree of hyperglycaemia. Blood glucose should be monitored regularly and not be allowed to fall below 7 mmol/1

Glucose-potassium-insulin infusion (Alberti regimen)

— 16 units of soluble insulin and 10 mmol potassium chloride in 500 ml 10% glucose are infused at
100 ml/hour. The infusion should be started 1 hour before surgery and blood glucose measured after 2 hours.
If this is greater than 10 mmol/1 then the dose of insulin should be increased by 4 units and the blood glucose rechecked

• Miscellaneous requirements, e.g.:

— vocal cord check prior to thyroidectomy

— plain X-ray on the way to theatre to confirm the position of a stone prior to ureterolithotomy.

12 Bowel preparation: Patients' requirements and surgeons' preferences differ greatly. No single regimen will work perfectly on every patient, but it is wise to have a standard preparation to describe, which can also apply to colonoscopy. A typical regimen might be:

• Stop any constipating agents and iron preparations 3-4 days pre-operatively.

• Low-residue diet, and preferably fluid diet for 48 hours prior to surgery.

• Adequate purgation on afternoon prior to surgery, to produce fluid diarrhoea, e.g. magnesium sulphate (2-hourly doses until copious diarrhoea is produced), Klean-prep, Picolax, etc.

• Water, saline or purgative (bisacodyl) enemas administered 1-2 hours pre-operatively until returns are clear.

• Other possible regimens include total gut irrigation with 6-10 litres of isotonic saline infused via a nasogastric tube, or the oral ingestion of a mannitol solution (100 g in 1 litre of water) (this latter regimen should not be used for colonoscopy if diathermy polypectomy is to be used as there is then an increased risk of an explosion).

Any regimen should be modified if there is any evidence of obstruction or active inflammatory bowel diseases

Orally administered non-absorbable antibiotics have now been superseded by intravenous prophylactic antibiotics.

Anaesthesia (general or local)

The decision as to which form of anaesthesia is most appropriate may depend on:

• The procedure

• The patient (see ASA grading below)

• The preference of the anaesthetist and/or surgeon.

The American Society of Anaesthetists grading (ASA) relates patient fitness to outcome after anaesthesia but takes no account of age:

I Normal healthy individual

II Mild systemic disease

III Severe, but not incapacitating, systemic disease

IV Incapacitating systemic disease constantly 'threatening life

V Moribund patient not expected to survive 24 hours irrespective

of intervention
E Suffix for emergency surgery.

General anaesthesia

• With or without full muscle relaxation

• With or without endotracheal intubation

• With or without positive pressure ventilation.

Local anaesthesia

• E.g. 1% or 2% lignocaine

• With or without adrenalin (adrenalin should not be used with lignocaine in the digits or in any area where vasoconstriction may lead to ischaemia.

• Permitted doses are given in Table

• Doses may be calculated by knowing that a 1 % solution contains
10 mg/ml. Therefore: 20 ml of a 1% solution contains 200 mg;

40 ml of a 0.5% solution contains 200 mg.

Special techniques

• Epidural: A Tuohy needle is used to introduce 6-20 ml of marcaine 0.25-0.5% into the epidural space. This gives a lumboabdominal block, which, although it takes rime to establish, can be topped up via a cannula. Opiates, such as 2 mg morphine, are currently used in this manner.

• Spinal: A 22-25 size needle is used to enter the subarachnoid space. After CSF is drawn, 3 ml of 0.5% marcaine or 1.5 ml cinchocaine are introduced. It is a useful technique for quick anaesthesia, but is not suitable for long-term purposes, as a cannula cannot be left in the subarachnoid space for fear of infection. Its onset takes about 10 minutes and lasts for about 1.5 hours.

Caudal: This route provides ideal analgesia in children for circumcision or herniae. The injection is made via the sacral hiatus, but is not so popular in adults as the hiatus is closed in 10-15%, and large doses are necessary for effective anaesthesia.

• Regional block: This technique is particularly appropriate for day-case hemiorrhaphies, e.g. ilio-inguinal block at the anterior superior iliac spine, combined with local infiltration and an injection into the neck of the sac.

• Bier's block: This is especially valuable for setting Colles' fractures. A cuff is placed around the upper arm, and a butterfly needle placed in both arms, one for access to the circulation (on the good hand) and the other to instill the anaesthesia. After elevation, the cuff is inflated and 20-30ml of 0.5% prilocaine injected. 0.2% marcaine has been used but has been known to cause cardiac arrests. The cuff should not be deflated in less than 20 minutes, after which the agent is fixed to the tissues. After the cuff is deflated, a careful watch is made for any signs of toxicity.

Monitoring

• Pulse oximeter (although there is no real alternative to careful clinical observation)

• ECG

• Blood pressure

— Von Recklinghausen's oscillotenometer

— automatic blood pressure devices, e.g. dinamap

• Central venous pressure

• Arterial pressure line

• Swan-Ganz balloon catheter to measure pulmonary artery wedge pressure.

Special requirements of anaesthesia

• No muscle relaxants if using the nerve stimulator at parotidectomy

• For bowel anastomoses avoid using neostigmine or atropine, or use them sparingly and carefully

• Thoracic surgery usually requires a double lumen endotracheal tube such as the Carlen or Robert Shaw tube. High-frequency jet ventilation is a useful advance, especially when dealing with a bronchopleural fistula, as the lungs do not go in and out, owing to a small tidal volume, with a high ventilatory rate.

• A bloodless field is vital for neurosurgical procedures, like clipping a berry aneurysm, plastic surgery and some ENT surgery. It is also useful during prostatectomy, parotidectomy and hip replacements. It requires a good premed and deep anaesthesia, and, if the pressure is still too high, beta-blockers will control cardiac rate and hydralazine will lead to vasodilatation. The more powerful sodium nitroprusside must be used carefully as it produces cyanide, and therefore must only be used up to a maximum dose of 1.5 mg/kg body weight.

Position on the table

• Supine: flat on the table and face up, e.g. routine abdominal surgery

• Prone: flat on the table and face down, e.g. excision of a pilonidal sinus

• Lithotomy: hips fully flexed and feet supported on lithotomy poles, e.g. transurethral surgery

• Lloyd Davies: hips semi-flexed and abducted with calves supported on Lloyd Davies stirrups and a sand bag linger the sacrum, e.g. abdominoperineal resection of the rectum

• Lateral: full lateral with table broken, e.g. nephrectomy

• Semilateral, e.g. thoracoabdominal approach.

Position of the table

• Head up (reversed Trendelenberg), e.g. to empty veins for head and neck surgery such as thyroidectomy or
parotidectomy

• Head down (Trendelenberg), e.g. anterior resection and other pelvic surgery

• Table tilted laterally, e.g. to improve access in certain thoracic procedures.

Skin preparation Possible solutions for skin preparation

• Chlorhexidine 0.59c in 70% alcohol with or without a dye

• Betadine: povidone-iodine 10% in alcohol

• Aqueous solutions for use in open wounds, face, genitalia, etc.:

— chlorhexidine 0.15 g/1 in cetrimide 1.5 g/1

— chlorhexidine 0.2 g/1 in water.

Describe the drapes and their attachment — towel clips or sutures (avoid towel clips being in the field of view of intraoperative radiology, e.g. operative cholangiography).

Other forms of wound protection:

• Op-site

• Vidrape wound protectors

• Steridrape.

Open surgery

All incisions should be described in relation to specific surface markings.

Point out any specific hazard or requirements of the incision, e.g.:

• Avoid the marginal/mandibular branch of the facial nerve when making the incision for excision of the submandibular gland

• Include a cephalad extension of the lower abdominal incision for an anterior resection for mobilization of the splenic flexure.

Describe the various layers that are encountered, e.g.:

Skin

Subcutaneous fat
Deep fascia
Aponeurosis
Muscle
Peritoneum, etc.

Laparoscopic surgery

For each laparoscopic procedure describe:

• Patient position and theatre set-up

• Instrument check, e.g. insufflator, camera

• Insertion of first port and induction of pneumoperitoneum

— open insertion (Hasson) — now most surgeons' preferred method

— Verres needle use

• Secondary port insertions — sizes and sites

• Potential hazards of insertion

• Special instrument or equipment requirements, e.g. specimen retrieval bag, staplers, retractors, intraoperative ultrasound.

Initial assessment

Describe any factors that may influence the procedure in hand, e.g.:

Liver metastases

Peritoneal seedlings

Anatomical abnormalities, especially in the biliary tree

Severe intraperitoneal adhesions

Synchronous dual pathology.

All intra-abdominal procedures, especially those for trauma, must include a full laparotomy. It is vital to have a formal sequence for this procedure in order to avoid omitting any organ from adequate scrutiny.

Formal laparotomy

A suitable methodical sequence may be as follows:

• Stomach

— both anterior and posterior aspects

— open lesser sac

• Pancreas: body and tail can be assessed once lesser sac is open

• Hiatus and diaphragm

— assess size of hiatus

— exclude hernia or rupture

• Duodenum

— Kocherize duodenum — this allows assessment of pancreatic head

— fourth part of duodenum is assessed by reflecting up the transverse colon and dividing the ligament of Treitz

• Liver: assess for consistency and presence of masses

• Gallbladder

— look for stones

— assess calibre of common bile duct

— examination with finger in the foramen of Winslow helps assess lower common bile duct and head of pancreas

• Spleen: assess size as well as consistency

• Small bowel

— look for Meckel's diverticulum

— mesenteric cysts

— nodes, tumours or inflammatory lesions

— vascular abnormalities

• Appendix and caecum: look for faecoliths or tumours

• Colon and rectum

— look for polyps

— tumours

— inflammatory bowel disease

— diverticular disease

• Pelvic organs

— uterus

— tubes

— ovaries

• Retroperitoneal structures

— kidneys: size, shape, position

— ureters: any hold up or dilatation

— bladder: tumour, stones, diverticulum

— aorta: aneurysmal dilatation

— inferior vena cava.

The actual procedure

For each procedure, whether open or laparoscopic, describe:

Mobitization

Give details of the actual anatomical manoeuvres and what instruments are used, i.e.:

• Which retractors, e.g.:

— Joll's for thyroidectomy

— Finochieto or Price Thomas for a thoractomy

— Balfour for a laparotomy

• Any special packing procedure for open procedures, e.g. packing off the hepatic flexure of the colon during cholecvstectomy

• What structures are divided or mobilized, e.g.:

— the peritoneal reflection in a hemicolectomy

— the strap muscles are separated in a thvroidectomy

Any resection

Give details of margins of resection and define extent of resection

• i.e. for bowel, what clamps are used, e.g.:

— Lane's twin gastric clamps

— Hays Lows clamp for anterior resection

— Zachary Cope's clamp for an end colostomy

• Define extent of resection, e.g.:

— subtotal thyroidectomy for thyrotoxicosis

— superficial parotidectomy for pleomorphic adenoma

— limits for a hemicolectomy

• Describe any pedicle ligation, e.g.:

— renal pedicle: artery before vein to prevent engorgement

— high inferior mesenteric tie for anterior resection

— ligation of superior and inferior thyroid arteries during thyroidectomy

Intraoperative procedures

• operative cholangiogram during cholecystectomy

• on-table arteriogram after vascular reconstruction

• on-table radiology to assess completeness of nephrolithotomy

• use of nerve stimulator during superficial parotidectomy

Reconstruction

Describe methods of anastomosis and materials used:

• Anterior resection, e.g. end-to-end anastomosis using a single
layer of interrupted vicryl sutures, prolene, staples, etc.

• Gastric anastomosis, e.g. using two layers of haemostatic
continuous absorbable sutures such as polyglycolic acid

• Continuous single layer of prolene for vascular anastomoses

• Closing mesentery during bowel resection

• Closing lateral space after colostomy formation.

Potential hazards and their prevention

Point out any particular hazards to the procedure described and also
describe what measures you would take to avoid them, e.g.:

• Laparoscopic procedures present the potential hazards of damaging bowel or vessels during port insertion.

• At right hemicolectomy you need to avoid damage to the ureter and duodenum while the right colic vein can easily be torn.

• At superficial parotidectomy you need to avoid damage to the facial nerve. Careful use of the nerve stimulator, scrupulous haemostasis, and patient, painstaking technique, often with operating loops, should help avoid such damage.

• The recurrent laryngeal nerve is easily damaged during

thyroidectomy when the inferior thyroid artery region is being dissected. Some surgeons seek to avoid damage by not actively
looking for the nerve. However, the author believes the nerve should always be displayed whenever possible.

• The tail of the pancreas can be damaged when ligating the splenic vessels, especially during emergency splenectomy.

Closure of the wound Describe the wound or port site closure:

• Layers to be closed, e.g.:

— peritoneum

— muscle layer: linea alba

—- subcutaneous tissue

— skin

• Suture materials used, e.g.:

— nylon

— prolene

— catgut

— dexon

— vicryl, etc.

• Form of suture, e.g.:

— interrupted

— vertical mattress suture

— deep tension suture

— subcuticular suture

— steristrips, etc.

It must be realized that the method of closing wounds becomes an individual matter of preference, as far as both technique and suture material are concerned. However, mass closure of a laparotomy is now the most widely accepted technique, using non-absorbable monofilament nylon, taking large bites of tissue and using plenty of suture length (suture length at least four times the length of the wound).

For any anastomosis or wound closure, tension is anathema and must be avoided at all costs, especially in procedures like mastectomy or amputation flaps.

Drains

Describe any drains used in the procedure. This is again a matter of individual preference, but in deciding which type of drain to use you need to consider:

• What is it draining?

— air, e.g. underwater seal chest drain

— blood

— pus

— potential contamination, e.g. cystic duct, bowel anastomosis

— urine

• How long should it be left in and why?

— until it stops draining

— 24 hours

— 5 days

• How should it be managed postoperatively?

— suction (redivac, sterivac)

— low-pressure suction, e.g. Roberts pump

— underwater seal (chest drain)

— free drainage into dressing

— free drainage into closed system

— shortened daily

• How should it be removed?

— by shortening daily until it falls out

— removed completely after a certain period of time

— removed after a sinogram.

Postoperative management

You may be required to give practical advice as to how the patient is managed postoperatively.

General factors

Postoperative pain relief
Fluid replacement
Electrolyte requirements
Blood replacement
Physiotherapy to the chest
General monitoring, i.e.:

— pulse

— temperature

— blood pressure

urinary output

— nasogastric aspirate

— other drainage, etc.

Specific factors

These will depend on the procedure:

• Thyroidectomy

— watch for evidence of:

— haemorrhage

— tracheal compression

— monitor serum calcium

— check cords

• Vascular surgery

— watch drainage

— check limbs for pulses, temperature, capillary return

• Prostatectomy

— monitor urinary output

— management of:

— urinary catheter

— intracystic irrigation

• Gastrointestinal surgery: nasogastric tube

— free drainage?

— 4-hourly aspiration?

— spigatted?

— oral fluid restriction

Potential postoperative complications
Causes of operative failure

Pre-operative factors

• Faulty selection of cases

• Poor pre-operative preparation of patient

• Pre-existing intercurrent disease, e.g. myocardial ischaemia, poor respiratory reserve.

Operative factors

Poor technique, e.g. anastomoses

Poor haemostasis

Damage to adjacent organs

Poor judgement

Inadequate materials, e.g. sutures

Poor tissues, e.g. post-irradiation, ischaemia

Contamination and infection.

Postoperative factors

• Pulmonary atelectasis (collapse)

• Infection: intraperitoneal, wound, etc.

• Chronic cough

• Inadequate management of fluid balance and electrolytes.

Complications of surgery

Anaesthetic

Inadequate airway

Inadequate ventilation

Inadequate fluid replacement

Inadequate reversal of anaesthetic agents

Problems resulting from monitoring techniques, e.g. pneumothorax from subclavian venous line, distal ischaemia from arterial line.

Surgical

• Haemorrhage

— primary (ligature slip, etc.)

— secondary (infection)

— reactionary (postoperative rise in blood pressure)

• Poor technique, etc. (see above).

Postoperative

Site

• General, e.g.:

— pulmonary collapse

— deep vein thrombosis

— pulmonary embolism

— urinary retention

— metabolic sequelae

• Local, e.g.:

— haemorrhage

— infection: wound, etc.

— specific to that procedure, e.g. post-thyroidectomy:

— tracheal compression from bleed

— hypocalcaemia

— cord malfunction.

Timing

• Immediate (within 24 hours of surgery)

• Early (within 2-3 weeks of surgery)

• Late (remote from surgery).

Summary

1. Pre-operative preparation

2. Anaesthesia

3. Position on table

4. Skin preparation

5. Incision

6. Initial assessment

7. Actual procedure

8. Potential hazards and how to avoid them

9. Closure of the wound

10. Drains

11. Postoperative management

12. Potential postoperative complications.

Instruments

It is vital to know the names of specific instruments used in operative
procedures, e.g.:

• Retractors

• Clamps

• Forceps

• Purpose-designed instruments.

The examiner may have a selection of instruments in common use
available for the candidate to comment on, and he may wish to know:

• What they are called

• What they are used for

• How they are used.

There are a vast number of surgical instruments and those used in
any procedure will vary from hospital to hospital according to avail-
ability. However, for any particular operation, describe the instruments
you would use for each specific manoeuvre.

Do not forget to describe the types of suture or ligature used for
each manoeuvre.

Prophylactic antibiotics

Prophylactic use of antibiotics in potentially contaminated wounds is now accepted surgical practice. However, the use of such agents depends on both the clinical and bacteriological potential for such contamination.

Clinical potential for infection

• Clean: no breach of a mucosal surface, no local soiling, e.g. thyroidectomy

• Clean-contaminated: mucosal surface breached but procedure is clean, e.g. cholecystectomy

• Contaminated: a viscus containing large quantities of bacteria is entered, e.g. elective colorectal surgery

• Dirty: the wound is exposed to pus or infected visceral contents, e.g. colonic perforation.

Bacteriological potential for infection

This is defined by visceral and parietal swabs taken during the operation. The potential for infection in any wound is defined by the results of the swabs allowing for the classification presented.

• Clean: both visceral and parietal swabs sterile

• Potentially contaminated: visceral swab contaminated, parietal swab sterile

• Lightly contaminated: a single species grown from parietal swab

• Heavily contaminated: two or more species grown from parietal swab

It is vital to stress that the use of prophylactic antibiotics is in no way a substitute for scrupulous surgical and aseptic technique, but merely an adjunct. Other factors that affect the risk of sepsis include procedures-of longer than 2 hours' duration, the insertion of prostheses and any existing intercurrent disease process (e.g. rheumatic valve disease) or relevant medication (e.g. steroids). The use of such agents raises certain practical clinical questions.

When should they be given?

Prophylactic antibiotics are ineffective unless circulating within 2 or 3 hours of contamination. Therefore, the first dose should be given immediately before surgery — most conveniently at induction of anaesthesia.

Which antibiotics⁷

This depends on the potential bacterial contamination. With new antibiotics being frequently presented on the market it is impossible to be dogmatic, but as a general rule a broad-spectrum antibiotic like the cephalosporins is commonly used for upper abdominal surgery, combined with an anti-anaerobic agent like metronidazole for colorectal surgery. Some of the newer generation of antibiotics have both anti-aerobic and anti-anaerobic activity, and may be suitable for single-agent prophylaxis in this context.

For how long should it be given?

Initial evidence suggested that three doses were adequate for prophylaxis, although more recent evidence suggests that one dose only ay be effective and sufficient. However, if a procedure is prolonged, with duration of over 2 hours, then a further dose may be indicated. There is certainly no indication that more than three doses will provide any further protection as far as prophylaxis is concerned, but when one is treating an established infection — e.g. perforated diverticular disease — a longer course is usually necessary; but this then falls into the therapeutic category of 'treatment' rather than prophylaxis.

By which route?

Both intravenous or intra-incisional administration have proved effective in different series. Intravenous administration at the time of anaesthetic induction is most commonly used in everyday current practice. Rectal metronidazole has proved adequate prophylaxis for appendicectomy.

What are the potential problems?

• It may encourage the emergence of resistant strains, but this can be limited by limiting the course of antibiotics to a one- or three- dose regimen.

• Even one dose may cause later anaphylaxis.

Thromboembolic prophylaxis

Any patient undergoing surgical procedures is at risk of developing thromboembolic complications owing to the hypercoagulable state that is a component of the body's metabolic response to stress. This is exacerbated by underlying malignancy, sepsis, trauma, dehydration and emergency surgery. A past history of a thromboembolic episode, increasing age, obesity and a prolonged operative procedure also
increase the risk.

Prophylactic methods in current use

• Graded compression stockings (TED stockings). A good fit is required, and there should be no history of peripheral vascular disease, with foot pulses present.

• Pneumatic compression boots during surgery

• Subcutaneous heparin (5000 units .subcutaneously twice daily). This acts by inactivation of thrombin and factor Xa by enhancement of antithrombin III activity. Newer low-molecular- weight heparins inactivate factor Xa only, and need to be administered only once a day (e.g. enoxaprin 20-40 mg sc od).

Additional risk factors include:

Obesity

Varicose veins

Pregnancy

Immobility

Hypercoagulable states

Recent surgery

Sepsis

Dehydration

Trauma or emergency surgery.

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