Preventing Surgical Complications: A Practical Guide

Surgical complications, whilst never entirely eliminable, are in many cases preventable through careful planning, meticulous technique, and attention to established best practices. Over the course of my career, I have found that the most effective approach to complication prevention is a systematic one, where every stage of the surgical process is approached with the same rigour and attention to detail.

Pre-Operative Planning

The single most effective way to prevent surgical complications is thorough pre-operative preparation. This begins well before the patient enters the operating theatre.

• Patient assessment: Complete physical examination, appropriate haematology and biochemistry, and any additional diagnostics indicated by the patient's history or proposed procedure
• Risk stratification: Identifying patients at higher risk of complications, such as geriatric patients, brachycephalic breeds, those with concurrent diseases, or those on medications that may affect coagulation or healing
• Surgical planning: Reviewing the anatomy, considering the surgical approach, anticipating potential challenges, and ensuring the appropriate equipment and suture materials are available
• Team briefing: A pre-operative briefing with the anaesthetic and nursing team ensures everyone understands the plan, anticipated risks, and their respective roles

Aseptic Technique

Surgical site infections remain one of the most common post-operative complications. Strict adherence to aseptic technique is non-negotiable. Key principles include:

Patient preparation should involve clipping a generous margin around the surgical site, followed by a thorough surgical scrub using an appropriate antiseptic solution. The scrub technique matters as much as the solution used. Contact time should be adequate and the scrub should always move from the incision site outward.

Surgeon preparation includes a thorough hand scrub, sterile gowning and gloving, and maintaining sterile technique throughout the procedure. Glove perforation is more common than many surgeons realise, and double gloving should be considered for prolonged procedures or those involving orthopaedic implants.

Theatre discipline is equally important. Minimising traffic in and out of the operating theatre, maintaining appropriate ventilation, and ensuring all instruments and materials are properly sterilised all contribute to reducing infection risk.

Tissue Handling

Gentle tissue handling is a fundamental principle that directly affects healing outcomes. Tissues that are crushed, desiccated, or devascularised during surgery are more susceptible to infection and delayed healing.

• Use atraumatic techniques wherever possible, handling tissues with stay sutures rather than forceps when feasible
• Keep tissues moist with warm saline-soaked swabs, particularly during prolonged procedures
• Minimise the use of electrocautery on tissues that will be incorporated into the closure, as excessive thermal damage impairs healing
• Avoid excessive tension on tissue retractors, repositioning them regularly to prevent ischaemic damage

Haemostasis

Achieving thorough haemostasis without excessive tissue damage is one of the core skills of surgical practice. Haematoma formation creates dead space, impairs wound healing, and provides an ideal medium for bacterial growth.

I prefer a layered approach to haemostasis. Identify and ligate significant vessels before transection where possible. Use electrocautery judiciously for small vessel haemostasis, avoiding charring tissue. Consider the use of haemostatic agents in areas where direct ligation is impractical. Always check for haemostasis before closure by briefly increasing the patient's blood pressure if the anaesthetist is able to do so safely.

Suture Selection and Closure Technique

Choosing the appropriate suture material and closure technique for each tissue layer is critical. The wrong choice can lead to dehiscence, infection, or excessive tissue reaction.

• Suture size: Use the smallest suture size that will hold the tissue adequately. Over-sized sutures create more tissue reaction and potential for infection
• Material selection: Monofilament sutures generally produce less tissue reaction and harbour fewer bacteria than multifilament materials. Absorbable sutures should be chosen based on the required duration of wound support
• Closure tension: Sutures should approximate tissue edges without strangulation. Excessive tension leads to tissue necrosis and increases the risk of dehiscence
• Dead space management: Closing dead space with walking sutures or placing drains where appropriate reduces the risk of seroma and haematoma formation

Common Pitfalls to Avoid

Through experience and honest reflection on cases that have not gone as planned, I have identified several common pitfalls that contribute to surgical complications:

1. Rushing: Time pressure is a reality in practice, but cutting corners during surgery invariably costs more time in managing complications afterward
2. Inadequate exposure: A small incision may look tidier, but inadequate surgical access leads to blind dissection, accidental tissue damage, and incomplete procedures
3. Ignoring small bleeds: Minor haemorrhage that seems insignificant during surgery can accumulate to form a significant haematoma post-operatively
4. Skipping the surgical count: Retained swabs and instruments are entirely preventable through consistent use of surgical counts
5. Poor record keeping: Detailed surgical notes enable better post-operative care and are invaluable if complications arise