Surgical Decision-Making and Perioperative Care

🟢 Lite — Quick Review (1h–1d)

Rapid summary for last-minute revision before your Saudi GP Board Surgery paper.

Surgical decision-making in general practice hinges on four sequential steps: preoperative assessment, risk stratification, operative planning, and postoperative care. The ASA Physical Status Classification (I–VI) is the bedside tool that summarises a patient’s comorbidity burden before surgery. Informed consent is documented across five domains — indication, risks, benefits, alternatives, and capacity — not merely a signature. Antibiotic prophylaxis must be given within 60 minutes before skin incision for most agents; vancomycin and fluoroquinolones require a longer 120-minute window. For wound closure, clean surgical wounds heal by primary intention, contaminated wounds by secondary intention, and delayed closures use tertiary (delayed primary) intention.

GP referral threshold: persistent red-flag symptoms (bleeding, weight loss, obstruction, palpable mass) warrant same-day or two-week-wait specialist referral.
VTE prophylaxis: Caprini-style risk assessment guides both mechanical (compression devices) and pharmacologic (LMWH) measures for immobilised patients.
Post-op day 1 triad to monitor: hemorrhage, infection, atelectasis — the three most-tested early complications.

🟡 Standard — Regular Study (2d–2mo)

Standard content for residents with weeks to months of preparation.

ASA Classification and Risk Stratification

The American Society of Anesthesiologists (ASA) physical status system is the lingua franca of perioperative risk communication. ASA describes the patient, not the procedure; this distinction is a classic exam trap. ASA I is a healthy patient; ASA III has severe systemic disease; ASA VI is a brain-dead organ donor.

ASA Class	Patient Status	GP Implication
I	Healthy, no medical problems	Day-case surgery appropriate
II	Mild controlled disease (well-controlled DM, mild obesity)	Minor optimisation, proceed
III	Severe systemic disease (stable angina, CKD stage 3)	Specialist input, may need HDU
IV	Severe disease, constant threat to life (recent MI, sepsis)	ICU-level care, defer if elective
V	Moribund, not expected to survive 24 h without operation	Resuscitation and emergency surgery

Consent is a process, not a form. The five required elements are indication (why the procedure is being proposed), risks (material and procedure-specific), benefits, alternatives (including no intervention), and capacity assessment (understanding, appreciation, reasoning, expressing choice). Capacity must be re-confirmed if clinical status changes between consent and operation.

Prophylactic Antibiotics and SSI Reduction

Surgical site infection (SSI) is reduced when prophylactic antibiotics achieve therapeutic tissue concentration before incision. For cefazolin, cefuroxime, and most β-lactams, the 60-minute pre-incision window is the standard; vancomycin and ciprofloxacin require infusion over ≥60 minutes, so they should start within 120 minutes of incision.

Antibiotic	Pre-incision Window	Redose Interval (long cases)
Cefazolin 2 g IV	≤ 60 min	4 hours
Vancomycin 15 mg/kg IV	≤ 120 min	Not routinely
Metronidazole 500 mg IV	≤ 60 min	8 hours

VTE Prophylaxis and Postoperative Surveillance

Caprini scoring assigns points for age, immobility, malignancy, prior VTE, and major surgery (≥3 points = high risk). Pharmacologic options include enoxaparin 40 mg SC daily; mechanical options include intermittent pneumatic compression. Active surveillance targets hemorrhage (drain output, haemoglobin trend), infection (wound inspection, WBC, CRP), and atelectasis (early ambulation, incentive spirometry).

Red-flag referral: unexplained weight loss + anaemia in adults ≥50 → urgent upper/lower GI pathway.
WHO Surgical Safety Checklist has three phases: sign-in (before anaesthesia), time-out (before incision), sign-out (before patient leaves theatre).
Always re-verify consent if a new intervention emerges intra-operatively.

🔴 Extended — Deep Study (3mo+)

Comprehensive coverage for deep preparation, edge cases, and exam strategy.

Wound Healing by Intention — Choosing the Closure Strategy

The mode of closure is decided preoperatively based on wound contamination, tissue loss, and infection risk. Selecting the wrong intention is a recurrent SCFHS question stem.

Intention	Indication	Typical Examples
Primary	Clean, uncontaminated, low-tension wounds	Inguinal hernia repair, thyroidectomy
Secondary	Contaminated or infected wounds with tissue loss	Perianal abscess, fasciotomy, pilonidal sinus
Tertiary (delayed primary)	Contaminated traumatic wounds observed for 4–7 days before closure	Combat injuries, contaminated abdominal wounds

Edge Cases and Common Traps

ASA ≠ surgical risk: a fit ASA I patient undergoing Whipple’s procedure still carries procedure-specific morbidity; conversely, an ASA III patient undergoing cataract surgery has minimal anaesthetic risk.
Antibiotic timing mistakes: giving ceftriaxone after incision negates prophylaxis benefit and is a SCFHS board-favourite wrong-answer distractor.
VTE in immobilised GP patients: post-cast application, prolonged bed rest after discharge, and post-laparoscopic surgery all require pharmacologic prophylaxis unless contraindicated.
Consent in minors: in Saudi Arabia, a guardian’s consent is required for minors; however, emancipated minors or emergency life-saving care can proceed without it.

Practice Prompts

A 62-year-old with insulin-dependent diabetes and stable CKD stage 3 presents for elective cholecystectomy. Assign ASA class, select antibiotic prophylaxis and timing, and outline VTE prophylaxis.
A contaminated abdominal wound from a farm injury is debrided on day 1. By which intention should it be closed, on what day, and what two specific dressing milestones indicate readiness?

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Surgical Decision-Making and Perioperative Care