For achieving the desired optimum results in a surgical patient, apart from evaluating the nature and extent of the diseases and choice of surgery from available options, the assessment of the patient for his ability to withstand the stress of surgery and anaesthesia is very important. The factors that must be considered in preoperative assessment are:

•           The disease (and its extent) for which the surgery is planned.

•           The condition of the patient and his organ systems.

•           The relative urgency of the surgery.

•           The type of surgery and its alternatives.

•           The relative morbidity and mortality of the disease.

•           The relative morbidity and mortality of the surgical procedure.

All these factors are interdependent and this assessment is the most fundamental task to be performed in a surgical patient. The best person to undertake this task is the surgeon himself. Surgeon and other specialists may, at times, need the help of a physician, cardiologist, paediatrician or anaesthetist, to take the right decision. The preoperative assessment should also include discussion on drugs being taken by the patient and documentation of known allergies.

1.  Informed consent

Informed consent on the presented format should be taken after a detailed discussion by the surgeon (or his responsible assistant) with the patient and his close relatives, informing them about the nature of the procedure planned, benefits expected, risks involved and possible alternatives, giving full opportunity to them to ask questions and clear doubts.

2.  Preoperative preparation

•               Routine investigations- Hb, TLC. DLC, CT, BT, RBS, LFT, KFT, HBsAg, HCV, HIV test, Urine routine examination, and in patients over 30 years, Chest X-ray and ECG.

•               Special and specific investigations depending upon the nature of the procedure planned and the physical condition of the patient for evaluating fitness for surgery.

•               Lipstick, nail polish and other cosmetics which may mask cyanosis and interfere with pulse oximetry should be removed.

•               Dentures, spectacles, contact lenses, artificial limbs, artificial eyes, hearing aid and jewellery, cash and mobile phones should be removed before shifting the patient to operation theatre and instructions should be given to the patient.

•               Withholding feeds before surgery depending upon age of the patient and nature of anaesthesia and surgery planned.

•               Bathing. If possible, patient should take a proper bath on the day prior and on the morning of surgery giving special attention to the operative area. Patient should wear only clean hospital clothing.

•               Hair removal should be done as close to the time of surgery as possible. If the skin is to be shaved, it is best done immediately before surgery. These are best removed with a clipper or chemical depilator. Shaving results in damage to skin and leads to abrasions that may not be visible.

•               One should ask for history of allergic reactions to any chemical solutions.

•               While scrubbing, one should work away from the operative site. Visibly soiled skin should be washed with soap and water before using surgical scrub.

•               Pre anaesthetic medication as per policy.

Skin preparation for surgery

Preoperative surgical antisepsis aims at blocking infection into surgical wound and consists of washing, gloving along with application of antiseptic to surgical site. Different surgical scrubs available for skin preparation before surgical procedure include any of the following:

•     Povidone iodine

The mechanism of action of povidone-iodine is the release of free iodine that binds to bacteria. Agent has excellent activity against gram-positive bacteria and good activity against gram-negative bacteria, viruses and fungi. Povidone iodine's free iodine attracts and binds with organic substances, modifying or decreasing its antiseptic effectiveness in the presence of blood. Removing organic lances such as blood, pus, or fat from the surgical site yields optimal results with use of a povidone e agent. Disadvantage is minimal persistent and residual activity and decreased effectiveness in the presence of blood and organic material

•     Chlorhexidine gluconate

The mechanism of action for this broad-spectrum agent is disruption of the cell membranes by cytologic and physiologic changes that lead to cell death. It is effective against all categories of microbes, namely bacteria, viruses and yeasts. Chlorhexidine gluconate is classified as moderate in relation to the rapidity of action and has excellent persistent and residual activity. Chlorhexidine gluconate has been shown to remain effective in the presence of serum and protein- rich biomaterial, is blood. Disadvantage is that it is contraindicated for use on eyes, ears, brain and spinal tissue, ha, mucus membranes and it is inactivated in the presence of saline solution, has drying effect on n. Accumulative benefit of chlorhexidine when repeatedly applied.

Use a combination of a rapid-acting agent (alcohol) and a longer lasting agent (chlorhexidine) is recommended.

•     Alcohol

(70% ethyl or isopropyl alcohol), it is 95% effective against gram negative and gram-positive bacteria, mycobacteria, fungi and viruses It is not completely effective against spores All traces of alcohol should be dry before drapes are put. Alcohol is never used on mucus membranes and open wounds as it may cause desiccation