An operation is a series of steps, and the steps need to be followed in sequence. The same is true of pre-operative preparation before any major surgical procedure. Atul Gawande, who is a very enjoyable author, recently published a book called The CheckList Manifesto which explored the use of checklists to manage complex tasks like flying airplanes and performing surgery. This book has become instrumental in shaping the procedures used at hospital to improve patient safety. I like to use a series of checklists to make sure that the appropriate steps have been taken at each step along the way. This process begins when we perform complete a history and physical examination, review the appropriate imaging data such as the MRI scan and X-rays, and determine a treatment plan.
Once the diagnosis is confirmed and you agree that surgical correction is desirable we will complete a pre-operative checklist that ensures that the following goals have been met:
- You should be properly educated about the condition, the risks and benefits of surgery, and expectations for treatment
- You should be evaluated prior to surgery by your primary MD and be considered “fit” to undergo a major operation
- Pre-operative laboratory testing and an EKG has been completed
- A surgical plan has been formulated and your questions have been answered.
Prior to the day of surgery, there are a few things that you can do that will improve the outcome after surgery. The most important of which is a skin decontamination procedure. Recently, the national institutes of health and several major medical centers around the united states have completed a series of clinical trials on what patients should do at home PRIOR to surgery in order to decrease the chances of developing an infection post-operatively. These studies were specifically designed to find out whether or not a program of pre-operative decontamination resulted in a reduction in the number of post operative infections — and the answer was resounding — THESE PROGRAMS WORK.
The most common routine for preoperative decontamination of the skin involves using an ointment in your nose for 5 days prior to surgery and using a special type during your daily shower or bath 1 or 2 days before your operation. First, the OINTMENT. The nostrils (called the nares by medical doctors) is a warm and inviting place for bacteria to set up shop. Approximately 25 to 30 percent of the general population has a particular type of bacteria in their nostrils called MRSA — methicillin resistant staph aureus. This is a very common bacteria that normally lives on the skin that has become resistant to antibiotics over the past 20 years and it is a common culprit in post-operative infections. To reduce the chance that you are an MRSA carrier at the time of your operation, you apply an ointment called bactroban to the inside of your nostrils, twice a day for 5 days before the operation. Bactroban is the brand name for the medication, Mupirocin is the generic name, and the tube looks like this.
Second, the SOAP. Your skin is covered with bacteria. While the surgical team will clean your skin thoroughly before beginning a procedure, research has shown that using a particular type of soap called hibiclens during your shower for 1-2 days before surgery helps reduce the chance of an infection. This soap is available in most pharmacies and it looks something like this. We will also provide you with a prescription for this soap.
It is important that you complete this cleaning routine prior to surgery because it has definitively been shown to reduce your chance of developing a surgical site infection post-operatively.