The creation of a stoma is a technical exercise. Like most undertakings, if done correctly, the stoma will usually function well with minimal complications for the remainder of the ostomate’s life. Conversely, if created poorly, stoma complications are common and can lead to years of misery. Intestinal stomas are in fact enterocutaneous anastomoses and all the principles that apply to creation of any anastomosis (i.e., using healthy intestine, avoiding ischemia and undue tension) are important in stoma creation.
Despite good preoperative assessment, surgical and anaesthetic technique and perioperative management, unexpected symptoms or signs arise after operation that may herald a complication. Detecting these early by regular monitoring and surgical review means early treatment can often forestall major deterioration. Managing problems such as pain, fever or collapse requires correct diagnosis then early treatment. Determining the cause can be challenging, particularly if the patient is anxious, in pain or not fully recovered from anaesthesia. It is vital to see and assess the patient and if necessary, arrange investigations, whatever the hour, when deterio-ration suggests potentially serious but often remediable complications. Consider also whether and when to call for senior help.
Medical students are often attached to the various services. They can provide a significant contribution to patient care. However, their work requires supervision by the surgical intern/resident who takes primary clinical responsibility. Subinterns are senior medical students who are seeking additional clinical experience. Their assistance is needed and appreciated, but again, close supervision of their clinical responsibilities by the intern/resident is mandatory.Outside reading is recommended, including textbooks, reference sources, and monthly journals.Eating is prohibited in patient care areas.Maintain patient confidentiality at all times.At conferences use only patient initials in presentations; and speak carefully and respectfully on work rounds.
1. Always be punctual (this includes ward rounds, operating room, clinics, conferences, morbidity and mortality). Personal appearance is very important. Maintain a high standard including clean shirt and tie (or equivalent) and a clean white coat. The day begins early. Be ready with all the data to start rounds with the senior resident or chief resident. Be sure to provide enough time each morning to examine your patients before rounds.
2.Aim to get all of your chart notes written as soon as possible; this will greatly increase your effi ciency during the day. Sign and print your name, and include your beeper number, date, and time. Progress notes on patients are required daily. Surgical progress notes should be succinct and accurate, briefl y summarizing the patient’s clinical status and plan of management. Someone unfamiliar with the case should be able to get a good understanding of the patient’s condition from one or two notes. Operative consent is obtained after admitting the patient, performing the history and physical examination, discussing the risks, benefi ts, and alternatives of the procedure(s), and having the patient’s nurse sign the consent with the patient. If you are unaware of the risks and benefi ts of a procedure, discuss this with the service chief resident. Blood transfusion attestation forms need to be signed by the counseling physician before each surgical procedure.
3. Arrive in the operating room with the patient and before the attending physician or chief resident. Make sure that the charts and all of the relevant x-rays are in the operating room. Make sure that the x-rays are on the x-ray view box prior to the commencement of the case. The intern or resident performing the case should be familiar with the patient’s history and physical exam, current medications, and comorbidities, and be familiar with the principles of the operation prior to arriving in the operating room. Make it a habit to introduce yourself to the patient before the operation. It is mandatory that the surgical resident involved with a case in the operating room attend the start of the case punctually. Scheduled operative cases do not necessarily occur at the listed time. For this reason, it is necessary to check with the operating room front desk frequently. Do not rely on being paged. Conduct in the operating room includes assisting with the preoperative positioning and preparation of the patient; this includes shaving, catheterization, protection of pressure points, and thromboembolism protection. The resident should escort the patient from the operating room to the intensive care unit (ICU) or the postanesthetic care unit with the anesthesiologists. The operating surgeon is responsible for dictating the case. The resident must record all cases performed. For cases admitted to the surgery ICU, a hand-over to the surgery ICU resident is mandatory.This includes discussing all the preoperative assessment, operative details, and postoperative management of the case with the ICU resident.
4. Signing out to cross-cover services must be performed in a meticulous and careful fashion. All patients should be discussed between the surgical intern and the cross-covering intern to cover all potential problems. A sign-out list containing all the patients, patient locations, and the responsible attendings should be given personally to the cross-cover intern. Any investigations performed at night (e.g., lab studies, chest x-ray, electrocardiogram [ECG]) should be checked that night by the covering intern. No test order should go unchecked. Abnormal lab values should be reviewed and discussed with the senior resident or the attending staff, especially on preoperative patients. Starting antibiotics should be a decision left to the senior resident or attending staff. If consultants are asked to see patients, their recommendations mustbe discussed with your senior resident or attending priorto initiating any new plans. Independent thought is good; independent action is bad.
5. Document all procedures performed on patients—including arterial lines, chest tubes, and central lines—with a short procedure note in the chart. Every patient contact should be documented in the patient record.If you see a patient in the middle of the night, write a short note to describe your assessment and plan. Remember, if there is no documentation, then nobody responded to the patient’s complaint or needs. Obtain appropriate supervision for procedures. There are always more senior residents available if your chief is not. Protect yourself; practice universal precautions! Wash your hands before and after examining a patient. Wear gloves. All wounds should be inspected every day by the surgical intern as part of the clinical examination. Please re-dress them; the nursing staff is not always immediately available to do so. There should never be any surprises in the morning.
Your senior resident is responsible for the service and should be kept aware of any problems, regardless of the time of day. If the senior resident is not available, the attending staff should be contacted directly. There are always senior residents in the hospital who are available to be used as resources for emergencies. Always be aware of who is in-house (i.e., consult resident, ICU resident, trauma chief). A surgery resident’s days are long. They start early and they fi nish late. Always remember the three A’s to being a successful resident: Affable, Available, and Able. Be prepared to maintain a flexible daily schedule depending on the workload of the service and the requirement for additional manpower.
Colon surgery represents a high number of patients treated at a department of gastrointestinal surgery and is not limited to colon cancer. It includes other non-neoplastic pathologies such as inflammatory bowel disease, diverticular disease or colonic volvulus. As with any major procedure, colon surgery patients may present serious or even fatal complications. The incidence of postoperative complications from colon surgery has been estimated at between 10% and 30% according to selected series. Preventive measures against surgical complications include selection of an appropriate procedure for the patient as well as good preoperative care, appropriate surgical technique and good postoperative management. When diagnosis has been established, risks for patient should be assessed according to patient’s health conditions and type of surgery accomplished. When the patient meets the surgical requirements, an appropriate course of preoperative care should be carried out including colon wash antibiotics and antithrombotic prophylaxis. Postoperative period will be equivalent to any major abdominal surgery. Typically, it was considered appropriate to wait a few days before initiating feeding in order to protect anastomosis; however, some authors agree that an early oral diet hours after intervention is not associated with a higher risk of anastomotic dehiscence and other complications.