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1. Preoperativecare
Prior to surgery, the patient is given a medical examination, receives certain pre-
operative tests, and their physical status is rated according to the ASA physical
status classification system. If these results are satisfactory, the patient signs a
consent form and is given a surgical clearance. If the procedureis expected to
result in significant blood loss, an autologous blood donation may be made some
weeks prior to surgery. If the surgery involves the digestive system, the patient
may be instructed to perform a bowel prep by drinking a solution of polyethylene
glycol the night before the procedure. Patients are also instructed to abstain from
food or drink (an NPO order after midnight on the night before the procedure), to
minimize the effect of stomach contents on pre-operative medications and reduce
the risk of aspiration if the patient vomits during or after the procedure. Some
medical systems have a practice of routinely performing chest x-rays before
surgery. The premise behind this practice is that the physician might discoversome
unknown medical condition which would complicate the surgery, and that upon
discovering this with the chest x-ray, the physician would adapt the surgery
practice accordingly. In fact, medical specialty professional organizations
recommend against routine pre-operative chest x-rays for patients who have an
unremarkable medical history and presented with a physical exam which did not
indicate a chest x-ray. Routine x-ray examination is more likely to result in
problems like misdiagnosis, overtreatment, or other negative outcomes than it is to
result in a benefit to the patient. Likewise, other tests including complete blood
count, prothrombin time, partial thromboplastin time, basic metabolic panel, and
urinalysis should not be done unless the results of these tests can help evaluate
surgical risk.
Staging for surgery
In the pre-operative holding area, the patient changes out of his or her street clothes
and is asked to confirm the details of his or her surgery. A set of vital signs are
recorded, a peripheral IV line is placed, and pre-operative medications (antibiotics,
sedatives, etc.) are given. When the patient enters the operating room, the skin
surface to be operated on, called the operating field, is cleaned and prepared by
applying an antiseptic suchas chlorhexidine gluconate or povidone-iodine to
reduce the possibility of infection. If hair is present at the surgical site, it is clipped
off prior to prep application. The patient is assisted by an anesthesiologist or
resident to make a specific surgical position, then sterile drapes are used to cover
all of the patient's bodyexcept for the head and the surgical site or at least a wide

2. area surrounding the operating field; the drapes are clipped to a pair of poles near
the head of the bed to form an "ether screen", which separates the
anesthetist/anesthesiologist's working area (unsterile) from the surgical site
(sterile). Anesthesia is administered to prevent pain from incision, tissue
manipulation and suturing. Based on the procedure, anesthesia may be provided
locally or as general anesthesia. Spinal anesthesia may be used when the surgical
site is too large or deep for a local block, but general anesthesia may not be
desirable. With local and spinal anesthesia, the surgical site is anesthetized, but the
patient can remain conscious orminimally sedated. In contrast, general anesthesia
renders the patient unconscious and paralyzed during surgery. The patient is
intubated and is placed on a mechanical ventilator, and anesthesia is produced by a
combination of injected and inhaled agents. Choice of surgical method and
anaesthetic technique aims to reduce risk of complications, shorten time needed for
recovery and minimise the surgical stress response.
Surgery
An incision is made to access the surgical site. Blood vessels may be clamped or
cauterized to prevent bleeding, and retractors may be used to exposethe site or
keep the incision open. The approachto the surgical site may involve several
layers of incision and dissection, as in abdominal surgery, where the incision must
traverse skin, subcutaneous tissue, three layers of muscle and then peritoneum. In
certain cases, bone may be cut to further access the interior of the body;for
example, cutting the skull for brain surgery or cutting the sternum for thoracic
(chest) surgery to open up the rib cage. Whilst in surgery health and safety is used
to prevent infection or further spreading of the disease. The surgeon will remove
hair from the face and eyes, using a head hat. Hands, wrists and forearms are
washed thoroughly to prevent germs getting into the operated body, then gloves are
placed onto the hands. A PVC apron will be worn at all times, to stop any
contamination. A yellow substance – typically an antiseptic iodine solution – is
lighly coated onto the located area of the patient's body that will be performed on,
this stops germs and disease infecting areas of the body, whilst the patient is being
cut into.
Work to correct the problem in bodythen proceeds. This work may involve:
 excision – cutting out an organ, tumor, or other tissue.
 resection – partial removal of an organ or other bodily structure.
 reconnection of organs, tissues, etc., particularly if severed. Resection of organs such as
intestines involves reconnection. Internal suturing or stapling may be used. Surgical

3. connection between blood vessels or other tubular or hollow structures such as loops of
intestine is called anastomosis.
 Reduction – the movement or realignment of a body part to its normal position. e.g.
Reduction of a broken nose involves the physical manipulation of the bone and/or
cartilage from their displaced state back to their original position to restore normal
airflow and aesthetics.
 ligation – tying off blood vessels, ducts, or "tubes".
 grafts – may be severed pieces of tissue cut from the same (or different) body or flaps of
tissue still partly connected to the body but resewn for rearranging or restructuring of the
area of the body in question. Although grafting is often used in cosmetic surgery, it is
also used in other surgery. Grafts may be taken from one area of the patient's body and
inserted to another area of the body. An example is bypass surgery, where clogged blood
vessels are bypassed with a graft from another part of the body. Alternatively, grafts may
be from other persons, cadavers, or animals.
 insertion of prosthetic parts when needed. Pins or screws to set and hold bones may be
used. Sections of bone may be replaced with prosthetic rods or other parts. Sometime a
plate is inserted to replace a damaged area of skull. Artificial hip replacement has become
more common. Heart pacemakers or valves may be inserted. Many other types of
prostheses are used.
 creation of a stoma, a permanent or semi-permanent opening in the body
 in transplant surgery, the donor organ (taken out of the donor's body) is inserted into the
recipient's body and reconnected to the recipient in all necessary ways (blood vessels,
ducts, etc.).
 arthrodesis – surgical connection of adjacent bones so the bones can grow together into
one. Spinal fusion is an example of adjacent vertebrae connected allowing them to grow
together into one piece.
 modifying the digestive tract in bariatric surgery for weight loss.
 repair of a fistula, hernia, or prolapse
 other procedures, including:
 clearing clogged ducts, blood or other vessels
 removal of calculi (stones)
 draining of accumulated fluids
 debridement- removal of dead, damaged, or diseased tissue
Blood or blood expanders may be administered to compensate for blood lost during surgery.
Once the procedure is complete, sutures or staples are used to close the incision. Once the
incision is closed, the anesthetic agents are stopped and/or reversed, and the patient is taken off
ventilation and extubated (if general anesthesia was administered).
Post-operative care
After completion of surgery, the patient is transferred to the postanesthesia care
unit and closely monitored. When the patient is judged to have recovered from the
anesthesia, he/she is either transferred to a surgical ward elsewhere in the hospital

4. or discharged home. During the post-operative period, the patient's general
function is assessed, the outcome of the procedureis assessed, and the surgical site
is checked for signs of infection. There are several risk factors associated with
postoperative complications, such as immune deficienty and obesity. Obesity has
long been considered a risk factor for adverse post-surgical outcomes. It has been
linked to many disorders such as obesity hypoventilation syndrome, atelectasis and
pulmonary embolism, adverse cardiovascular effects, and wound healing
complications. if removable skin closures are used, they are removed after 7 to 10
days post-operatively, or after healing of the incision is well under way.
It is not uncommon for surgical drains (see Drain (surgery)) to be required to
remove blood or fluid from the surgical wound during recovery. Mostly these
drains stay in until the volume tapers off, then they are removed. These drains can
become clogged, leading to retained blood complications or abscess.neuro-
ophthalmology, ophthalmic pathology, ophthalmic plastic surgery, pediatric
ophthalmology and vitreoretinal diseases.
Oral and Maxillofacial Surgery
An oral and maxillofacial surgeon specializes in dentistry which includes the
diagnosis and surgical and adjunctive treatment of patients with disease, injuries,
and defects involving both the function and appearance of the oral and
maxillofacial region. This specialty includes care of the oral cavity and face,
removal of diseased and impacted teeth, anesthesia for dental procedures, dental
implants, facial trauma, pathologic conditions (tumors or cysts), reconstructive and
cosmetic surgery, facial pain including temporomandibular joint disorders,
correction of dentofacial (Bite) deformities, and birth defects. Certification requires
completion of training in an accredited residency program, evidence of post-
training experience, and successfulcompletion of written and oral examinations on
the entire scopeofthe specialty.
Orthopaedic Surgery
An orthopaedic surgeon is trained in the preservation, investigation, and restoration
of the form and function of the extremities, spine, and associated structures by
medical, surgical, and physical means. Specialized care is provided for patients
with musculoskeletal problems including congenital deformities, trauma,
infections, tumors, metabolic disturbance of the musculoskeletal system,
deformities, injuries, and degenerative disease of the spine, hands, feet, knee, hip,
shoulder, and elbow in children and adults. An orthopaedic surgeon also is

5. involved with treatment of secondary muscular problems in patients who suffer
from various central or peripheral nervous system lesions suchas cerebral palsy,
paraplegia, or stroke, as well as conditions that are treated medically or physically
through the use of braces, casts, splints, or physical therapy.
OrthopaedicSportsMedicine
An Orthopaedic Sports Medicine specialist provides care for all structures in the
musculoskeletal system directly affected by participating in sporting events. The
specialist is proficient in the conditioning, training, and fitness of the bodyas it
relates to athletic performance and the effects of athletic performance and the
impact of dietary supplements, pharmaceuticals, and nutrition on athletes' short-
and long-term health and performance.
Surgery of the Hand
A specialist in this area is trained in the investigation, preservation and medical
surgical and rehabilitation treatment of patients with diseases, injuries, or
abnormalities affecting the upper extremities. This specialty includes the
performance of microvascular surgery, which is necessary for reattachment of
amputated fingers or limbs.
Otolaryngology – Head and Neck Surgery
An otolaryngologist—head and neck surgeon—provides medical and surgical care
for patients with diseases and disorders that affect the ears, nose, throat, the
respiratory and upper alimentary systems, and related structures of the head and
neck. They diagnose and provide medical and surgical treatment of diseases and
have skills and knowledge in audiology and speech-language pathology; the
chemical senses; allergy, endocrinology, and neurology as they relate to the head
and neck. Operations are performed on the head and neck, and face. Head and neck
oncology, facial plastic and reconstructive procedures, and the treatment of
disorders of hearing and voice are fundamental areas of expertise for the
otolaryngologist.
Specialty certification in otolaryngology—head and neck surgery includes:
Neurotology

6. A neurotologist is an otolaryngologist—head and neck surgeon—who treats
patients with diseases of the ear and temporal bone, including disorders of hearing
and balance.
Pediatric Otolaryngology
An otolaryngologist—head and neck surgeon— has completed specialty training in
the management of infants and children with congenital or acquired disorders of
the head and neck, nose, paranasal sinuses, ear, and aerodigestive tract.
Plastic Surgery within the Head and Neck
An otolaryngologist—head and neck surgeon—has completed additional training
in plastic cosmetic and reconstructive procedures within the head, face, and neck.
This area includes skin, head and neck oncology and reconstruction, management
of maxillofacial trauma, softtissue repair and neural surgery.
Plastic Surgery
Plastic surgeons specialize in the care of patients requiring repair, replacement, and
reconstruction of defects of the form and function of the bodycovering and its
underlying musculoskeletal system, with emphasis on the craniofacial structures,
the oropharynx, the upper and lower limbs, the breast, and the external genitalia.
This surgical specialty also focuses on the aesthetic surgery of structures with
undesirable form. Special knowledge and skill in the design and transfer of skin
flaps, in the transplantation of tissues, and in the replantation of structures are vital
to the performance of plastic surgery.
Specialty certification in orthopaedics includes:
Thoracic and Cardiovascular Surgery
Thoracic surgeons specialize in management of patients with conditions of the
chest and heart. This specialty includes providing surgical care of patients for
coronary artery disease; cancers of the lung, esophagus, and chest wall;
abnormalities of the heart, great vessels and heart valves; congenital anomalies;
tumors of the mediastinum; and diseases of the diaphragm. The management of the
airway and injuries to the chest are also areas of surgical practice for the thoracic
surgeon. They have specialized knowledge of cardiorespiratory physiology and

7. oncology, as well as capability in the use of extracorporeal circulation, cardiac
assist devices, management of cardiac dysrhythmias, pleural drainage, respiratory
supportsystems, endoscopy, and other invasive and noninvasive diagnostic
technique.
Urology Surgeon
A surgeon who specializes in urology manages patients with benign and malignant
(cancerous) medical and surgical disorders of the adrenal gland and of the
genitourinary system. Urologists have comprehensive knowledge of, and skills in,
endoscopic, percutaneous, and open surgery of congenital and acquired conditions
of the reproductive and urinary systems.
Types of Heart Surgery
Coronary Artery Bypass Grafting
Coronary artery bypass grafting (CABG) is the most common type of heart
surgery. CABG improves blood flow to the heart. Surgeons use CABG to treat
people who have severe coronary heart disease (CHD). CHD is a disease in which
a waxy substancecalled plaque (plak) builds up inside the coronary arteries. These
arteries supply oxygen-rich blood to your heart. Over time, plaque can harden or
rupture (break open). Hardened plaque narrows the coronary arteries and reduces
the flow of oxygen-rich blood to the heart. This can cause chest pain or discomfort
called angina (an-JI-nuh or AN-juh-nuh). If the plaque ruptures, a blood clot can
form on its surface. A large blood clot can mostly or completely block blood flow
through a coronary artery. This is the most common cause of a heart attack. Over
time, ruptured plaque also hardens and narrows the coronary arteries. During
CABG, a healthy artery or vein from the bodyis connected, or grafted, to the
blocked coronary artery. The grafted artery or vein bypasses (that is, goes around)
the blocked portion of the coronary artery. This creates a new path for oxygen-rich
blood to flow to the heart muscle. Surgeons can bypass multiple blocked coronary
arteries during one surgery.
Coronary Artery Bypass Grafting
CABG isn't the only treatment for CHD. A nonsurgical procedure that opens
blocked or narrow coronary arteries is percutaneous coronary intervention
(PCI), also known as coronary angioplasty. During PCI, a thin, flexible tube with a
balloon at its tip is threaded through a blood vessel to the narrow or blocked

8. coronary artery. Once in place, the balloon is inflated to push the plaque against
the artery wall. This restores blood flow through the artery. During PCI, a stent
might be placed in the coronary artery to help keep it open. A stent is a small mesh
tube that supports the inner artery wall. If both CABG and PCI are options, your
doctorcan help you decide which treatment is right for you.
Transmyocardial Laser Revascularization
Transmyocardial (tranz-mi-o-KAR-de-al) laser revascularization (re-VAS-kyu-lar-
ih-ZA-shun), or TMR, is surgery used to treat angina. TMR is most often used
when no other treatments work. Forexample, if you've already had one CABG
procedureand can't have another one, TMR might be an option. For some people,
TMR is combined with CABG. If TMR is done alone, the proceduremay be
performed through a small opening in the chest. During TMR, a surgeon uses
lasers to make small channels through the heart muscle and into the heart's lower
left chamber (the left ventricle). It isn't fully known how TMR relieves angina. The
surgery may help the heart grow tiny new blood vessels. Oxygen-rich blood may
flow through these vessels into the heart muscle, which could relieve angina.
Heart Valve Repair or Replacement
For the heart to work well, blood must flow in only one direction. The heart's
valves make this possible. Healthy valves open and close in a precise way as the
heart pumps blood. Each valve has a set of flaps called leaflets. The leaflets open
to allow blood to pass from one heart chamber into another or into the arteries.
Then the leaflets close tightly to stop blood from flowing backward. Heart surgery
is used to fix leaflets that don'topen as wide as they should. This can happen if
they become thick or stiff or fuse together. As a result, not enough blood flows
through the valve. Heart surgery also is used to fix leaflets that don'tclose tightly.
This problem can cause blood to leak back into the heart chambers, rather than
only moving forward into the arteries as it should. To fix these problems, surgeons
either repair the valve or replace it with a man-made or biological valve. Biological
valves are made from pig, cow, or human heart tissue and may have man-made
parts as well. To repair a mitral (MI-trul) or pulmonary (PULL-mun-ary) valve
that's too narrow, a cardiologist (heart specialist) will insert a catheter (a thin,
flexible tube) through a large blood vessel and guide it to the heart. The
cardiologist will place the end of the catheter inside the narrow valve. He or she
will inflate and deflate a small balloon at the tip of the catheter. This widens the
valve, allowing more blood to flow through it. This approachis less invasive than
open-heart surgery. Catheters also might be used to replace faulty aortic valves.

9. For this procedure, the catheter usually is inserted into an artery in the groin (upper
thigh) and threaded to the heart. They will thread the catheter into the heart
through the small opening. The catheter has a deflated balloon at its tip with a
folded replacement valve around it. The balloon is used to expand the new valve so
it fits securely within the old valve.
.Arrhythmia Treatment
An arrhythmia (ah-RITH-me-ah) is a problem with the rate or rhythm of the
heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an
irregular rhythm. Many arrhythmias are harmless, but some can be serious or even
life threatening. If the heart rate is abnormal, the heart may not be able to pump
enough blood to the body. Lack of blood flow can damage the brain, heart, and
other organs. Medicine usually is the first line of treatment for arrhythmias. If
medicine doesn'twork well, your doctormay recommend surgery. Forexample,
surgery may be used to implant a pacemaker or an implantable cardioverter
defibrillator (ICD). A pacemaker is a small device that's placed under the skin of
your chest or abdomen. Wires connect the pacemaker to your heart chambers. The
device uses low-energy electrical pulses to controlyour heart rhythm. Most
pacemakers have a sensorthat starts the device only if your heart rhythm is
abnormal. An ICD is another small device that's placed under the skin of your
chest or abdomen. This device also is connected to your heart with wires. An ICD
checks your heartbeat for dangerous arrhythmias. If the device senses one, it sends
an electric shockto your heart to restore a normal heart rhythm. Another
arrhythmia treatment is called maze surgery. Forthis surgery, the surgeon makes
new paths for the heart's electrical signals to travel through. This type of surgery is
used to treat atrial fibrillation, the most common type of serious arrhythmia.
Simpler, less invasive procedures also are used to treat atrial fibrillation. These
procedures use high heat or intense cold to prevent abnormal electrical signals
from moving through the heart.
Aneurysm Repair
An aneurysm (AN-u-rism) is a balloon-like bulge in the wall of an artery or the
heart muscle. This bulge can occurif the artery wall weakens. Pressure from blood
moving through the artery or heart causes the weak area to bulge. Over time, an
aneurysm can grow and burst, causing dangerous, often fatal bleeding inside the
body. Aneurysms also can develop a split in one or more layers of the artery wall.
The split causes bleeding into and along the layers of the artery wall. Aneurysms in
the heart most often occurin the heart's lower left chamber (the left ventricle).

10. Repairing an aneurysm involves surgery to replace the weak section of the artery
or heart wall with a patch or graft.
Heart Transplant
A heart transplant is surgery to remove a person's diseased heart and replace it with
a healthy heart from a deceased donor. Most heart transplants are done on patients
who have end-stage heart failure. Heart failure is a condition in which the heart is
damaged or weak. As a result, it can't pump enough blood to meet the body's
needs. "End-stage" means the condition is so severe that all treatments, other than
heart transplant, have failed. Patients on the waiting list for a donorheart receive
ongoing treatment for heart failure and other medical conditions. Ventricular assist
devices (VADs) or total artificial hearts (TAHs) might be used to treat these
patients.
Ventricular Assist Devices or Total Artificial Hearts
A VAD is a mechanical pump that is used to supportheart function and blood flow
in people who have weak hearts. Your doctormay recommend a VAD if you have
heart failure that isn't responding to treatment or if you're waiting for a heart
transplant. You can use a VAD for a short time or for months or years, depending
on your situation.
A TAH is a device that replaces the two lower chambers of the heart (the
ventricles). You may benefit from a TAH if both of your ventricles don'twork well
due to end-stage heart failure.
Open-Heart Surgery
Open-heart surgery is any kind of surgery in which a surgeon makes a large
incision (cut) in the chest to open the rib cage and operate on the heart. "Open"
refers to the chest, not the heart. Depending on the type of surgery, the surgeon
also may open the heart. Once the heart is exposed, the patient is connected to a
heart-lung bypass machine. The machine takes over the heart's pumping action and
moves blood away from the heart. This allows the surgeon to operate on a heart
that isn't beating and that doesn'thave blood flowing through it. Open-heart
surgery is used to do CABG, repair or replace heart valves, treat atrial fibrillation,
do heart transplants, and place VADs and TAHs.
Off-Pump Heart Surgery

11. Surgeons also use off-pump, or beating heart, surgery to do CABG. This approach
is like traditional open-heart surgery because the chest bone is opened to access the
heart. However, the heart isn't stopped, and a heart-lung bypass machine isn't used.
Off-pump heart surgery isn't right for all patients. Work with your doctorto decide
whether this type of surgery is an option for you. Your doctorwill carefully
consider your heart problem, age, overall health, and other factors that may affect
the surgery.
Diagnostic Tests
Tests are done to find out more about your heart problem and your general health.
This helps your doctors decidewhether you need heart surgery, what type of
surgery you need, and when to do it.
EKG (Electrocardiogram)
An EKG is a painless, noninvasive test that records the heart's electrical activity.
"Noninvasive" means that no surgery is doneand no instruments are inserted into
your body. The test shows how fast the heart is beating and its rhythm (steady or
irregular). An EKG also records the strength and timing of electrical signals as
they pass through the heart.An EKG can show signs of heart damage due to CHD
and signs of a previous or current heart attack.
Stress Test
Some heart problems are easier to diagnose when your heart is working hard and
beating fast. During stress testing, you exercise to make your heart work hard and
beat fast. If you can't exercise, you may be given medicine to raise your heart rate.
As part of the test, your blood pressure is checked and an EKG is done.
Other heart tests also might be done.
Echocardiography
Echocardiography (echo) is a painless, noninvasive test. This test uses sound
waves to create a moving picture of your heart. Echocardiography shows the size
and shape of your heart and how well your heart chambers and valves are working.

12. The test also can show areas of poorblood flow to your heart, areas of heart
muscle that aren't working well, and previous injury to your heart muscle caused
by poorblood flow.
Coronary Angiography
Coronary angiography (an-jee-OG-rah-fee) is a test that uses dye and special x rays
to show the insides of your coronary arteries.To get the dye into your coronary
arteries, your doctorwill use a procedurecalled cardiac catheterization (KATH-eh-
ter-ih-ZA-shun).A thin, flexible tube called a catheter is put into a blood vessel in
your arm, groin (upper thigh), or neck. The tube is threaded into your coronary
arteries, and the dye is released into your bloodstream.Specialx rays are taken
while the dye is flowing through the coronary arteries. These
x rays are called angiograms.
The dye lets your doctorstudyblood flow through the heart and blood vessels.
This helps your doctorfind blockages that can cause a heart attack.
Aortogram
An aortogram is an angiogram of the aorta. The aorta is the main artery that carries
blood from your heart to your body. An aortogram may show the location and size
of an aortic aneurysm.
Chest X Ray
A chest x ray creates pictures of the structures inside your chest, such as your
heart, lungs, and blood vessels. This test gives your doctorinformation about the
size and shape of your heart. A chest x ray also shows the position and shape of the
large arteries around your heart.
Cardiac Computed Tomography Scan
A cardiac computed tomography (to-MOG-rah-fee) scan, or cardiac CT scan, is a
painless test that uses an x-ray machine to take clear, detailed pictures of the
heart.Sometimes an iodine-based dye (contrast dye) is injected into one of your
veins during the scan. The contrast dye highlights your coronary (heart) arteries on
the x-ray pictures. This type of CT scan is called a coronary CT angiography, or
CTA. A cardiac CT scan can show whether plaque is narrowing your coronary

13. arteries or whether you have an aneurysm. A CT scan also can find problems with
the heart's function and valves.
Cardiac Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is a safe, noninvasive test that uses magnets,
radio waves, and a computer to create pictures of your organs and tissues.Cardiac
MRI creates images of your heart as it is beating. The computer makes both still
and moving pictures of your heart and major blood vessels.Cardiac MRI shows the
structure and function of your heart. This test can show the size and location of an
aneurysm.
Orthopedic surgery
Orthopedic surgery or orthopedics (alternatively spelled orthopaedic surgery and
orthopaedics)is the branch of surgery concerned with conditions involving the
musculoskeletal system. Orthopedic surgeons use bothsurgical and nonsurgical
means to treat musculoskeletal trauma, spine diseases, sports injuries, degenerative
diseases, infections, tumors, and congenital disorders.