Tag: surgery

After surgery, patients always ask, “Doctor, do I need to use antibiotics to prevent infection?”

Surgical incisions are usually closed by fixing the edges together with stitches, staples or steri-strips. This process helps the cut edges heal together and is called ‘healing by primary intention’. This has a very low potential for infection.

Minority of surgical wounds are not closed in this way. This happens when there is a high risk of infection. The wounds may be left open to heal by the growth of new tissue rather than by primary closure. This is known as ‘healing by secondary intention’.

There is a risk of infection in open wounds, which may impact on wound healing, and antiseptic or antibiotic treatments may be used to prevent infections.

We don’t have to use any topical antibiotics (like Polysporin or Neosporin) for surgical wounds which are clean. Yet we continue to promote its use for clean surgical incisions.

A clean surgical procedure requires a clean dressing that protects incisions from bacteria and keeps it clean and dry. Dressings should be changed daily or according to your doctor’s orders.

In a recent article (Five Things Clinicians and Patients Should Question) written under the leadership of the Canadian Dermatology Association in Choosing Wisely Canada (March 2019), the association advises Canadians not to routinely use topical antibiotics (like Polysporin) on a clean surgical wound.

This review article says that for wounds closed with stitches, the potential harms (like allergic contact dermatitis to topical ingredients and antibiotic resistance) outweigh the marginal reduced risk of postoperative infection achieved by use of antibiotics applied to the skin.

Only wounds that show symptoms of infection (pus, swelling, spreading redness, wound breakdown and systemic symptoms) should receive appropriate antibiotic treatment.

In another study published in 2015 (J Dermatolog Treat) the authors compared topical antibiotic prophylaxis for prevention of surgical wound infections and found no statistically significant difference in incidence of postsurgical wound infections between topical antibiotics (like Polysporin) and petroleum jelly.

The authors of the article recommend use of Petrolatum (petroleum jelly) instead of topical antibiotics as a prophylactic measure to prevent postsurgical wound infections in the outpatient dermatologic setting.

Other studies have shown with repeated usage, about 10 per cent of people will develop an allergy to local use of antibiotic ointment. These same studies have shown that white petrolatum jelly (Vaseline) is the preferred wound care agent after skin procedures. All you need is gentle daily soap/water cleansing, and applications of Vaseline.

What is petroleum jelly? Petroleum jelly (also called petrolatum) is a mixture of mineral oils and waxes, which form a semi-solid jelly-like substance. This product hasn’t changed much since Robert Augustus Chesebrough discovered it in 1859. Petroleum helps seal your skin with a water-protective barrier. This helps your skin heal and retain moisture.

What is Polysporin? Polysporin consists of two antibiotics, bacitracin and polymyxin B.

What is Neosporin? Neosporin consists of three different antibiotics, neomycin sulfate, polymyxin B sulfate and bacitracin.

There are many studies which encourage use of petroleum jelly for routine care of superficial wounds, because it is as effective for wound healing as over-the-counter antibiotic preparations and does not contribute to antibiotic resistance or allergic contact dermatitis.

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In minimally invasive surgery, doctors use a variety of techniques to operate with less damage to the body than with open surgery. Minimally invasive surgery is associated with less pain, a shorter hospital stay and fewer complications.

This advantage is achieved by using a technique called laparoscopy where surgery is done through one or more small incisions, using small tubes and tiny cameras and surgical instruments.

Laparoscopic technique was one of the first types of minimally invasive surgery. Another type of minimally invasive surgery is robotic surgery. It provides a magnified, 3-D view of the surgical site and helps the surgeon operate with precision, flexibility and control.

It was in 1902, Georg Kelling from Dresden in Germany performed laparoscopic surgery using dogs. In 1910, Hans Christian Jacobaeus from Sweden used the approach to operate on a human. Over the next couple of decades, the procedure was refined and popularized by a number of people.

Laparoscopic gallbladder surgery (cholecystectomy) was introduced about 25 years ago. In 2011, cholecystectomy was the 8th most common operating room procedure performed in hospitals in North America.

Now laparoscopy has become the approach of choice for cholecystectomy. Other laparoscopic surgical procedures are appendectomy, nephrectomy, hysterectomy and other gynecological procedures. Just like anything else in life, these procedures are not without complications – during or after surgery.

If the laparoscopic surgery is difficult to perform and if the surgeon feels this may cause harm to the patient then the procedure is converted into an open one. Patient has to understand this and give consent to the surgeon to do whatever is safe for the patient.

To make sure that the surgical procedures are carried out safely, the operating room follows a protocol, which takes into account the following:

• Perform a surgical pause (time out) to confirm the procedure with the team prior to initiating surgery.
• Verify that the correct materials or equipment was available and functional prior to use.
• Consider potential harm from misuse of surgical equipment.

Possible intra-operative injuries include damage to the bowel, blood vessels, ureter, reproductive organs, or nerves. The complication rate during surgery increase if the patient is obese and there are adhesions from previous surgeries.

How quickly you can return to normal activities after a cholecystectomy depends on which procedure your surgeon uses and your overall health. People undergoing a laparoscopic cholecystectomy may be able to go back to work in a matter of days. Those undergoing an open cholecystectomy may need a week or more to recover enough to return to work.

In 95 per cent of people undergoing cholecystectomy as treatment for simple biliary colic, removing the gallbladder completely resolves their symptoms. Up to 10 per cent of people who undergo cholecystectomy develop a condition called post-cholecystectomy syndrome. That means patient has symptoms typically similar to the pain and discomfort of biliary colic. Small number of patients may get chronic diarrhea after surgery. This can be controlled with medication like cholesteramine.

Overall, it is a very safe procedure.

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OK, don’t worry. It is not that common. In an article published in the Journal of the American College of Surgeons (January 2013) titled, “Retained Surgical Items: A Problem Yet to Be Solved,” by Stanislaw P.A. Stawicki, MD, and others says retained surgical items (RSI) continue to occur. But the exact numbers are difficult to document due to the low frequency of RSI in a single institution and due to the medicolegal implications.

Literature suggests retained surgical items have traditionally been estimated to occur at a rate of 0.3 to 1.0 per 1,000 abdominal operations, and approximately 1 in 8,000 to 18,000 of all inpatient operations.

Seven teaching institutions were invited to participate in this retrospective, multicenter, case-control study of RSI risk factors was conducted between January 2003 and December 2009. Fifty-nine RSIs and 118 matched controls were analyzed (RSI incidence 1 in 6,975 or 59 in 411,526). Retained surgical items occurred despite use of confirmatory x-rays (13 of 27 instances) and/or radiofrequency tagging (2 of 32 instances).

The researchers concluded:
-higher body mass index

-unexpected intraoperative events
-longer procedure duration and
-occurrence of any safety omissions like an incorrect count were associated with increased RSI risk.

Trainee presence was associated with 70 per cent lower RSI risk compared with trainee absence. The researchers are not sure why this would be the case. This requires further study. They further say, “Our findings highlight the need for zero tolerance for safety omissions, continued study and development of novel approaches to RSI reduction, and establishing anonymous RSI reporting systems to better track both the incidence and risks associated with this problem, which has yet to be solved.”

As one can expect, the operating room is a complex environment where technology, team dynamics, potent pharmaceuticals, and technically difficult operations create high potential for adverse events.

The researchers highlight at least three major obstacles to reducing the incidence of RSI, including locating missing items identified by an incorrect count, reducing the rate of incorrectly-correct counts, and improving team attentiveness and compliance with safety procedures and documentation.

If you are having surgery in the near future then remember, the incidence of retained surgical items is extremely small. The people who work in the operating rooms are highly trained and dedicated and your safety, I am sure, is their first concern.

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