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The molecular biology of hepatopancreatobiliary cancer

Introduction As our understanding of the molecular mechanisms of cancer development and progression has advanced, we have seen significant improvements in therapeutic responses in patients. This arguably has been best illustrated in the field of breast cancer, where tamoxifen and trastuzumab (Herceptin) have transformed outcomes for millions of patients with disease once thought refractory to treatment. Furthermore, molecular profiling has enabled the stratification of tumours previously…

Perioperative care for hepato-pancreato-biliary surgery

Introduction Hepato-pancreato-biliary (HPB) surgery can present many challenges during the perioperative period. With an ageing population, there are increasing numbers of patients with significant comorbid conditions presenting for surgery. Although patient outcomes have improved with a number of advances in perioperative technique, there remains significant morbidity and mortality associated with major HPB surgical procedures. As a result, it is essential to ensure thorough preoperative assessment of…

Liver function and failure

Overview of liver functions and evolution The liver is the largest solid organ in the human body. It has a unique structure with a dual blood supply, being approximately one-third from the hepatic artery and two-thirds from the portal venous system. Within the liver substance, blood flows through sinusoids between plates of hepatocytes into central veins, which in turn join the hepatic veins draining into the…

Hepatic, biliary and pancreatic anatomy

This chapter will provide a basic anatomical foundation for performing liver, biliary and pancreatic surgery. Anatomical features that are clinically unimportant have been omitted. It is self-evident that surgeons operating in this area must have a full working knowledge of the anatomy of the liver, biliary system and pancreas. Furthermore, with ongoing advances in modern imaging techniques, surgeons must be able to translate their understanding of…

A perioperative safety and quality change management model and case study: Muda Health

Every system is perfectly designed to get the results it gets. — Paul Batalden, M.D. Introduction The surgical space is a high-risk environment where hazards lurk around every corner and for every patient. The patients who come to surgery are generally among the sickest and at more advanced stages of disease. The very act of treatment involves risky interventions that are often considerably invasive with vigorous…

Redesigning the operating room for safety

Why design matters? We have been designing hospital operating rooms (ORs) for nearly 300 years. One of the first such spaces was designed with seats so that observers at St Thomas Hospital in 1751 could watch and learn. Consequently, even today, ORs are often referred to as operating theaters. Prior to the establishment of ORs, surgical procedures took place on hospital wards, patient homes, or in…

Occupational well-being, resilience, burnout, and job satisfaction of surgical teams

Perioperative teams A well-functioning perioperative surgical team is central to achieving the quadruple aim. , Superior outcomes can only occur when surgical team members are well and engaged in the process of improved patient outcomes. Surgical high-performance results from a relatively permanent or persistent change of behavior or behavior potential resulting from instruction, training, and practice (intentional learning) or experience (incidental learning). The overall “health” of…

Surgical site and other acquired perioperative infections

Introduction When a patient awakens from anesthesia after surgery, they usually look at their wound site to see how big the incisional bandage is. Usually, the patient and their family are relieved to hear that the operation was a success and believe the whole ordeal is over, even though patients are generally informed before surgery that unexpected events, including infections, can develop during their recovery, even…

Enhancing medication safety during the perioperative period

Introduction This chapter presents an overview of medication safety hazards and mitigation strategies during the perioperative period. The goal of the chapter is to aid surgical team members to better appreciate the complexity and mitigate the risks of the medication use process. The perioperative environment is complex and marked by a high degree of safety hazards. Thankfully, this patient care setting has seen remarkable progress in…

Designing safe procedural sedation: adopting a resilient culture

Glossary of terms AGA American Gastroenterological Association ANZCA Australian and New Zealand College of Anaesthetists ASA American Society of Anesthesiologists ASGE American Society for Gastrointestinal Endoscopy BIS Bispectral Index BMI Body mass index BPS Balanced propofol sedation CAD Coronary artery disease CO Carbon monoxide CO 2 Carbon dioxide COPD Chronic obstructive pulmonary disease DM Diabetes mellitus ECG Electrocardiogram ED Emergency department EDNAPS Endoscopist-directed, nurses-administered propofol sedation…

Preoperative preparation of the surgical patient

Preparation of the surgical patient begins with a consideration of all phases of surgical care when preparing a patient for surgery. Classic preoperative, intraoperative, and postoperative phases should be on the mind of the surgeon when developing their recommended surgical therapy. Initial presentation of the patient often reveals considerable information about the physical and mental state of the patient and should help guide the surgeon in…

Prehabilitation and enhanced recovery after surgery

Introduction Background and history Enhancing recovery after surgery has, of course, been the goal of surgeons since the beginning of surgery. It was not until the 1990s, however, that what we now refer to as “enhanced recovery after surgery” (ERAS) began to take its more formalized, programmatic shape, initially under the name “Fast Track” surgery in a publication on coronary bypass patients showing shorter intensive care…

Human factors and ergonomics in the operating room

Defining human factors and ergonomics Human Factors/Ergonomics is the application of psychology and physiology for the purpose of designing products, processes, and systems with the purpose of increasing safety and comfort for the human that interacts within the product, process, or system and is divided into physical, cognitive, and organizational ergonomics. While “ergonomics” is the term commonly used throughout the rest of the world, North America…

Structured perioperative team communication

Structured and effective communication is critical to a successful operation and perioperative care. It plays an essential role in facilitating teamwork. We define communication as the transfer of information from one person to another or to a group of individuals, either via verbal language, gestures or cues, or written messages. Effective communication allows a message or concern to be efficiently and clearly delivered to and understood…

Dynamics of surgical teams

This important topic is evolving daily in operating rooms (ORs) around the world. Patients are living longer because of complex operations performed on a routine basis. Older and sicker patients are being treated. The margin for error to achieve excellent outcomes is smaller than ever before. Yet results are good and improving. This is largely due to teams working in a unified and coordinated fashion year…

Culture of safety

Background The concept of a healthy patient safety culture in the perioperative setting embraces a number of critical concepts for healthcare practitioners including: recognition of organizational vulnerability in the provision and sustainability of safe patient care; acknowledgment that reporting of patient safety events and near misses relies on a supportive environment; support for staff at all levels to work through identification and analysis of defects, as…

Systems thinking in the operating room

Introduction Background The gap between the current and desired states of healthcare has been increasingly well established. There are a number of sobering statistics offered to illustrate that healthcare delivery falls short of proposed standards. Providing adequate (much less exceptional) healthcare poses an incredible challenge, not only due to the ever-increasing complexity of the patients and pathophysiology involved but also due to the mounting intricacy of…

The scope and prevalence of perioperative harm

It is no doubt that perioperative harm is frequent. Surgery has been identified as the source of many unavoidable medical errors and deaths. However, recent studies have proved that many of these adverse events are preventable. , The success of clear processes and guidelines, effective communication and teamwork, improved collaboration, and the reduction of distractions have helped in identifying and improving current challenges in surgical care.…

The science of human error

What is human error? Human error is inescapable simply because we are human. Human error is an act that is not intended, may happen at random, and may not be fully preventable. Some words that may be used to describe human error include but are not limited to inadvertent, slip, lapse, mistake, or accident. The outcome that results from human error is usually undesirable and sometimes…

Tracheostomy

Goals/Objectives Indications Techniques Complications Tracheostomy Melanie W. Seybt Lana L. Jackson David J. Terris From Cameron JL, Cameron AM: Current Surgical Therapy, 10th edition (Mosby 2011) Overview Reports of tracheostomy date as far back as the fifteenth century; however, it was Chevalier Jackson who standardized the technique in 1909, reducing mortality rates from 25% to approximately 2%. The procedure has continued to evolve over the last century, as medical…