Preoperative and Operative Surgery Principles Key concepts for patient preparation and surgical procedures. 主講者：黃漢斌醫師 中山醫學大學附設醫院 外科部 消化外科 Preoperative Patient Preparation 1 Risk Assessment Evaluate comorbidities and optimize patient status. 2 Directed Investigation Perform targeted tests based on patient condition. 3 Communication Explain procedure, risks, and expected outcomes to patient. 印度神童 盲眼龍婆 Preoperative Patient Preparation 1 Risk Assessment Evaluate comorbidities and optimize patient status. 2 Directed Investigation Perform targeted tests based on patient condition. 3 Communication Explain procedure, risks, and expected outcomes to patient. Perioperative Decision Making Timing Anesthesia Determine optimal time for surgery. Select best anesthetic approach. 1 2 Site Choose appropriate surgical location. 3 技能高超的人， 能夠擊中別人所沒辦法擊中的目標 聰明才智的人， 能夠擊中別人所沒辦法看到的目標 Arthur Schopenhauer (1788 – 1860) German philosopher 在光天化日下看到 別人看不到的東西？ ⼿術風險評估與預警 智慧醫療可利用大數據和 AI 技術，分析患者病歷、影像數據、術前檢查 等資訊，預測手術風險，並提出預警資訊。 風險因素 評估方法 預警指標 年齡、性別、疾病 機器學習模型 手術併發症風險 深度學習算法 手術成功率預測 專家系統 手術風險等級 史 生理指標、影像數 據 術前評估結果 醫生可根據風險評估結果，制定更精準的手術方案，採取預防措施，降 低手術風險。 Transduodenal ampullectomy VS Pancreaticoduodenectomy Transduodenal ampullectomy VS Pancreaticoduodenectomy Surgical Risk Calculator Surgical Risk Calculator Procedure: 48150 - Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type Procedure: 48148 - Excision of ampulla of Vater procedure); with pancreatojejunostomy Risk Factors: 85 years or older, Mild systemic disease, HTN Risk Factors: 85 years or older, Mild systemic disease, HTN Note: Your Risk has been rounded to one decimal point. Outcomes Your Risk Average Risk Chance of Outcome Serious Complication 13.8% 14.2% Average Any Complication 16.4% 17.9% Average Pneumonia 1.0% 1.0% Average Cardiac Complication 0.9% 0.8% Above Average Surgical Site Infection 8.1% 13.2% Below Average Urinary Tract Infection 0.5% 0.4% Above Average Venous Thromboembolism 0.7% 0.9% Below Average Renal Failure 1.1% 1.9% Below Average Readmission 9.8% 9.5% Average Return to OR 3.2% 4.6% Below Average Death 0.8% 0.6% Above Average Discharge to Nursing or Rehab Facility 14.9% 4.7% Above Average Sepsis 5.5% 7.6% Below Average Predicted Length of Hospital Stay: 7.5 days Disclaimer: The ACS Surgical Risk Calculator estimates the chance of an unfavorable outcome (such as a complication or death) after surgery. The risk is estimated based upon information the patient gives to the healthcare provider about prior health history. The estimates are calculated using data from a large number of patients who had a surgical procedure similar to the one the patient may have. Please note the risk percentages provided to you by the Surgical Risk Calculator are only estimates. The risk estimate only takes certain information into account. There may be other factors that are not included in the estimate which may increase or decrease the risk of a complication or death. These estimates are not a guarantee of results. A complication after surgery may happen even if the risk is low. This information is not intended to replace the advice of a doctor or healthcare provider about the diagnosis, treatment, or potential outcomes. ACS is not responsible for medical decisions that may be Note: Your Risk has been rounded to one decimal point. Outcomes Your Risk Average Risk Chance of Outcome Serious Complication 25.3% 29.1% Below Average Any Complication 28.3% 32.3% Below Average Pneumonia 3.5% 3.9% Average Cardiac Complication 2.2% 2.1% Average Surgical Site Infection 13.5% 21.4% Below Average Urinary Tract Infection 3.0% 2.1% Above Average Venous Thromboembolism 3.0% 3.6% Below Average Renal Failure 0.9% 1.6% Below Average Readmission 15.9% 17.9% Below Average Return to OR 3.8% 5.7% Below Average Death 1.5% 1.3% Above Average Discharge to Nursing or Rehab Facility 26.1% 9.4% Above Average Sepsis 6.5% 9.4% Below Average T Pancreatectomy Delayed Gastric 18.2% 15.4% Above Average Predicted Length of Hospital Stay: 9.5 days Disclaimer: The ACS Surgical Risk Calculator estimates the chance of an unfavorable outcome (such as a complication or death) after surgery. The risk is estimated based upon information the patient gives to the healthcare provider about prior health history. The estimates are calculated using data from a large number of patients who had a surgical procedure similar to the one the patient may have. Please note the risk percentages provided to you by the Surgical Risk Calculator are only estimates. The risk estimate only takes certain information into account. There may be Preoperative Evaluation Goals Identify Comorbidities Quantify Risk Optimize Status Uncover conditions affecting operative outcome. Assess potential for perioperative complications. Improve patient condition before surgery. ASA Classification ASA I Normal healthy patient ASA II Mild systemic disease ASA III Severe systemic disease ASA IV Life-threatening systemic disease ASA V Moribund patient ASA Classification 30-Day and 1-year mortality in emergency general surgery laparotomies: an area of concern and need for improvement? ASA I Normal healthy patient ASA II Mild systemic disease ASA III Severe systemic disease ASA IV Life-threatening systemic disease ASA V Moribund patient Cardiovascular Evaluation History Assess for cardiac symptoms and risk factors. Physical Exam Look for signs of cardiovascular disease. Tests ECG, stress tests if indicated. Cardiac Risk Indices Goldman Index Revised Cardiac Risk Index Eagle's Criteria Predicts cardiac complications Uses six predictors to estimate Assesses need for further cardiac based on clinical factors. cardiac risk. testing. Cardiac Risk Indices Goldman Index Revised Cardiac Risk Index Eagle's Criteria Predicts cardiac complications Uses six predictors to estimate Assesses need for further cardiac based on clinical factors. cardiac risk. testing. Cardiac Risk Indices Goldman Index Revised Cardiac Risk Index Eagle's Criteria Predicts cardiac complications Uses six predictors to estimate Assesses need for further cardiac based on clinical factors. cardiac risk. testing. ACC/AHA Guidelines Step 1 1 Assess urgency of surgery. 2 Step 2 Evaluate active cardiac conditions. Step 3 3 Determine surgical risk. 4 Step 4 Assess functional capacity. Step 5 Consider further cardiac testing if indicated. 5 膽石症簡介 膽石是指在膽囊或膽管內形成的結石。這些結石可能由膽汁中的膽固 醇或其他物質沉積而成。膽石症是一種常見的胃腸道疾病,可能會引起 嚴重的健康問題。及時診斷和治療非常重要。 膽囊管結石阻塞 Child-Pugh Classification Factor 1 point 2 points 3 points Bilirubin <2 mg/dL 2-3 mg/dL >3 mg/dL Albumin >3.5 g/dL 2.8-3.5 <2.8 g/dL g/dL PT <4 sec 4-6 sec >6 sec Ascites None Mild Moderate Encephalop None Grade I-II Grade III-IV athy 廣泛使用來評估術前肝功能的“幕內標準” Reverse T-shaped incision, for standard procedure using the Kent retractor Laparotomy combined with thoracotomy Side retractor J-shaped incision (only for rightsided) hepatic resection Boomerang retractor Surgical Devices and Energy Sources Scalpel Electrocautery Traditional cutting instrument. Uses electrical current for cutting and coagulation. Ultrasonic Devices Lasers Vibration-based cutting and coagulation. Focused light energy for precise tissue ablation. NIR/ICG guided hepatectomy Harmonic scalpel 超⾳波⼑ 腹腔鏡單極電燒勾 健保給付 Ligasure (⾃動凝集器) 想要了解更多關於 ligasure Wound Closure Techniques Sutures Staples Adhesives Various materials and patterns for Quick closure for skin and fascia. Tissue glues for small incisions. tissue approximation. Nutritional Evaluation 1 History Assess for weight loss and poor intake. 2 Physical Exam Look for signs of malnutrition. 3 Labs Check albumin and prealbumin levels. Perioperative Diabetic Management 1 Preop Steroid Supplementation Assess Risk Consider dose and duration of steroid use. Adjust insulin/oral agents, monitor glucose. Determine Need 2 Intraop Based on surgical stress and patient factors. Maintain glucose 140-180 mg/dL. 3 Postop Resume usual regimen when eating. Administer Give appropriate dose before and after surgery. Medication Management Continue Hold Adjust Beta-blockers, statins, Anticoagulants, certain diabetes Insulin, diuretics. antihypertensives. medications. Preoperative Checklist 1 Consent 2 Site Marking 3 NPO Status 4 Medications Verify informed consent Confirm surgical site Ensure appropriate Administer or hold is signed. is marked. fasting time. as indicated. Potential Causes of Intraoperative Instability Hypovolemia Blood loss, third-spacing. Cardiac Arrhythmias, ischemia. Respiratory Hypoxia, hypercarbia. Anesthetic Medication effects, malignant hyperthermia. Postoperative Care 1 Immediate Monitor vital signs, manage pain, assess bleeding. 2 Early Encourage early mobilization, resume oral intake. 3 Intermediate Remove drains/catheters, manage medications. 4 Late Plan follow-up, provide discharge instructions. Quality Improvement in Surgery NSQIP Checklists M&M Conferences National program for outcomes Standardized processes to Review complications to measurement and improvement. reduce errors. improve care. Future of Surgical Care Robotics Augmented Reality AI Integration Increased precision and minimally Enhanced visualization and guidance Improved decision support and invasive approaches. during procedures. predictive analytics. “We are currently preparing students for jobs that don’t yet exist, Using technologies that haven’t been invented, In order to solve problems we don’t even know are problems yet.” – Karl Fisch, Did You Know “我們⽬前正在為學⽣準備尚不存在的⼯作， 使⽤尚未發明的技術， 為了解決我們甚⾄還不知道是問題的問題。” —卡爾·費施，你知道嗎 42 智能⼿術輔助系統 機器⼿臂輔助 3D 模型導航 實時影像導引 數據分析與監控 機器手臂提供精準度與穩定 3D 模型幫助醫生了解病患的 實時影像顯示手術部位，提 手術過程中收集的數據，有 度，提升手術效率與精確性 解剖結構，進行更精準的手 高手術精度，減少手術風險 助於醫生更深入了解患者情 。 術規劃。 。 況，做出最佳決策。 Middle Ages 19th Surgery Open Laparoscopy 1867 1987 Single Port 1990 NOTES 2007 44 2013 超過全球超過50萬例的 機器⼿臂外科⼿術 Evolution of Surgery 45 46 47 Timeline of the Human Genome Project, 1990 - 2003 https://www.illumina.com/documents/products/illumina_sequencing_introduction.pdf Preoperative and Operative Surgery Principles Key concepts for patient preparation and surgical procedures 黃漢斌醫師 Wong Hon Phin MD