This starts with the patient from whom a careful history is taken. A focused physical examination is performed, and the complete medical status of the patient assessed. The likely diagnosis is considered on the basis of this clinical assessment, and confirmed by the appropriate test. Once confirmed, the specific treatment, be that medical or surgical, is advised. Should the likely diagnosis be wrong, attention is turned to the patient for further details of their ailment, and a more careful differential diagnosis considered as a basis for investigation. Continued observation over a limited period of time remains a powerful tool for achieving a diagnosis.
Despite current concepts, many patients with complaints requiring surgical treatment present with a simple history such as a lump or a pain for which a specific algorithmic approach will provide an answer. Experience will provide an answer for many patients who present with a physical sign, and no amount of history taking or examination will add to that visual assessment. A sebaceous cyst with its punctum standing proud is a simple surgical condition requiring a surgical exicision. The patient is operated upon, and the episode complete. Even the woman who presents with an ulcerating lump on her breast can be managed similarly in a diagnostic sense, but the knowledge attained in surgical study warns against a similar simplistic approach, and attention is turned to confirmation of the diagnosis noninvasively, so enabling full assessment of the whole patient on the basis of a confirmed pathology, often in co-operation with colleagues from other disciplines (Fig. 1.3).
Too little attention has been paid by the surgeon to the ancillary process of investigation, more so in some disciplines than others. Just as the stethoscope is helpful in diagnosis, so also ultrasonography, endoscopy and other forms of imaging will lead to a rapid confirmation of the clinical findings: an ultrasound scan is done to confirm gallstones (Fig. 1.4), a sigmoidoscopy to show a rectal carcinoma, a plain radiograph to confirm a fracture (Fig.1.5), magnetic resonance imaging (MRI) to show a prolapsed disc (Fig. 1.6) and an angiogram to define the cause of anginal pain. Each has a specific place in the surgical process, and each makes the operative approach more specific, but none is the sole reason for operation as the clinical approach dictates that an operation is only performed for a condition causing symptoms in a patient fit to withstand the procedure.
Thus, surgery is about risk assessment. The diagnosis is made, the fitness of the patient assessed, the procedure determined and the outcome known. Will that outcome benefit the patient? A tumour in the head of the pancreas, if left untreated, will kill the patient in 6 months, so treatment appears mandatory, yet the operation has a mortality of 10 per cent, the median survival is only extended by 12 months and the comorbid factors are high, such that many patients will derive little benefit from the extensive surgery (Fig. 1.7). However, a patient with a strangulated femoral hernia, which in the elderly patient carries a mortality risk of 10 per cent, particularly if bowel is resected, faces the same comorbidity risk as the patient who has pancreatic cancer, but is cured by the procedure, and hence there is no doubt that the operation is worthwhile and the procedure is undertaken., At present, such decisions are matters of judgement, butwith increasing knowledge of risk assessment, the correct procedure or management can be more easily calculated and fewer errors of judgement made. By and large, it is errors of judgement that cause surgical misadventure. By avoiding these errors through better and more exact diagnosis, preoperative care and postoperative management, the surgical management of patients will improve. The premortem procedure to prove that everything was done for the patient that could be done is no longer acceptable, and a more humane approach to terminal illness is required (Fig. 1.8).
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