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For centuries the surgeon's chief training was in anatomy, almost to the exclusion of other aspects of the art. Only in the 20th century did the increasing scope of surgery and unremitting efforts to reduce the number of deaths and complications to a minimum lead inevitably to the realization that a sound understanding of physiology is as important as a thorough grounding in anatomic relationships. In the 21st century, there is increasing interest in evidenced-based preoperative and postoperative care and the application of scientific knowledge and compassion to restore the patient to a normal physiologic state and equilibrium as readily as possible after minor or major surgery. The discipline of surgical critical care represents the ultimate merging of the art of surgery with the science of physiology.


The surgeon of the 21st century is concerned not only with the proper preoperative preparation of the patient and technical conduct of an operative procedure but also with the preparation of the operating room and an understanding of the problems created by illness in the patient as a whole. Because of the complexities of a patient population with many medical comorbid conditions, preoperative preparation may require a team approach. It is important for the surgeon to understand potential complications and their prevention and recognition. In the ideal situation, the preoperative preparation of the patient begins the ambulatory setting prior to admission. The surgeon assesses the patient and determines the need for surgery for the specific diagnosis. The surgeon advises the patient on the benefits and risks of the procedure in general as well as those that are specific to the operation being recommended. Informed consent is more than a signature on a piece of paper: it is a process of discussion and a dialogue between the surgeon and patient in which the patient has the opportunity to ask questions. The surgeon should also include a discussion of the possible use of blood products, and if deemed appropriate, advise the patient about autologous blood donation. In assessing the patient's condition it is important to identify major health issues. Pulmonary pathology including chronic obstructive pulmonary disease and asthma should be identified. Any departure from the norm disclosed by the history, physical examination, or the various procedures enumerated below may call for further specialty referral and treatment in concert with the patient's primary physician. Likewise, history of a myocardial infarction, valvular heart disease, or a previous coronary intervention may suggest the need for cardiac clearance and assessment by a cardiologist. Finally, if the patient's American Society of Anesthesiologists (ASA) class is III or IV, then it may be helpful to obtain an anesthesia consultation preoperatively. Written or verbal communication with the referring physician and primary care physician is important in order to facilitate continuity of care.


In many situations, the primary care physician may be engaged to help ready the patient for surgery. The primary physician may then set in motion diagnostic and therapeutic maneuvers that improve ...

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