Before surgery takes place, one prepares the patient in several ways. The staff install several electrodes and tubes to monitor and support bodily functions. They start the anesthesia and they prepare the patient so that the surgical work can be done in a safe and practical way. These measures will be in effect during surgery and after it they will be disconnected in a specific sequence.
The routines vary however from place to place. Greatest variation is perhaps to be found in the choice between general anesthesia or only localized anesthesia, especially for children.
Already before going to hospital all patients will be instructed to stop eating and sometimes the patient will be given a laxative to clean out all content from the digestive system. A few hours before surgery the patient must also stop drinking. At hospital some surgeries will require further cleansing by means of enemas.
When the patient arrives in hospital a nurse will receive him and he will be instructed to shift to some kind of hospital dressing, often a sort of pajama.
A nurse will take vitals. The anesthetist will visit the patient, talk with him and examine him shortly. Especially children will often get a plaster with numbing medication at sites where intravenous lines will be inserted at a later stage.
The patient or his parents will often be asked to sign a consent for anesthesia and surgery. In some societies consent is assumed, however, if objections are not stated at the initiative of the patient or the parents.
Then the nurse will often give the patient a sedative medication, typically midazolam (versed), usually as a fluid to swallow. Then they wheel the patient into a preparation room or right to the operating room.
Before anesthesia is initiated the patient will be connected to several devices that will stay during surgery and some time after: He will get a pulse oximeter on a finger or a toe to monitor oxygen saturation, a cuff around an arm or a leg to measure blood pressure, a tube called an intravenous line (IV) into a blood vessel in an arm, and electrodes at his upper body to monitor his heart activity.
Before proceeding the anesthetist will once again check all the vitals of the patient to ensure that he still is fit for surgery, or to detect abnormalities that require special attention. Right before the definite anesthesia the anesthetist may gives the patient a new dose of sedative medication, often propofol, through the IV line. This dose relaxes further, depresses memory, and often already makes the patient totally unconscious.
INDUCTION OF GENERAL ANESTHESIA
The anesthetist will start the general anesthesia by giving gas blended with oxygen through a mask. Once the patient is dormant, he will always get gas blended with a high concentration of oxygen for some while to ensure a good oxygen saturation in the blood.
If total muscle relaxation is wanted during surgery, a nurse will give a medication through the IV line that paralyzes muscles in the body, including the respiration, but not the heart.
Then the anesthetist will open up the mouth of the patient, look down inside his throat with a laryngosocope, and insert a laryngeal tube through his mouth and past the vocal cords, while using the laryngoscope as a guide for the insertion.
Then the patient will be given artificial ventilation through the laryngeal tube that provides oxygen and anesthetic gas continually during the whole surgery process.
They will strip the patient totally naked. More IV lines will now often be inserted into vessels at the lower body. He will typically also get more electrodes at the lower body to monitor the heart activity. Often a tube called a Foley catheter is inserted through the urethral opening into the bladder to drain the urine during surgery. A probe for measurements of temperature may also be inserted through the rectal opening or down the esophagus.
Sometimes they insert a tube through the rectal opening for flushing and drainage, and sometimes they also push a tube through the nose and down the esophagus into the stomach to keep the stomach empty for secrets or for instillation of nutrients after surgery.
A big electrode will be placed onto the body of the patient, most often under the buttocks which is necessary to make electric surgery tools work. Then the surgery site and a wide area around is painted with a solution of the yellow antiseptic agent betadine.
The nurses will lay the patient in the position necessary for surgery, and the patient is draped with blankets except at the surgical site and his face.
Some surgeries are performed without general anesthesia, but with numbing of body parts instead. Patients can also get localized anesthesia while under general anesthesia to alleviate pain after surgery.
By local anesthesia a numbing drug is injected in the local area where the surgery takes place. It is typically used by very small surgeries.
By regional anesthesia one injects the drug near to a nerve that serves a greater body part. Sometimes a thin catheter is also inserted that will remain to help give the patient more numbing drug during and after surgery.
By epidural anesthesia the drug is injected in the room inside the spine near the spinal cord, but over the dura mater and arachnoidea, which are two tissue sheets surrounding the spinal cord.
By spinal anesthesia one injects the medication inside the spine between the arachnoidea and pia mater. The pia mater is the immediate dressing of the spinal cord. It is typically used as main anesthesia for surgeries at the lower part of the body.
Also by these methods the patient will typically get some calming medication through an IV line in addition.
HOW THE SURGEON WORKS
The traditional scalpels for cutting and pinches to stop bleeding are now mostly replaced by more modern devices that achieve these two purposes simultaneously.
Much used is the harmonic knife, a peak probe through which alternating current is sent into the tissue so that it splits apart and blood coagulates. Another tool is a laser that cuts and stops the blood flow by heating up the tissue where the beam is pointed.
A coblation tool releases ions (electrically charged atoms) that have been energetically excited by an alternating voltage. The ions etch and dissolve tissue and the tool also sucks up the dissolved tissue.
By orthopedic surgery where bone is cut, the surgeon will typically use tools like electric saws and drills and in many ways work just like a carpenter. In addition to needle and thread the surgeon often uses means like staples and glue also to recompose tissue. By surgery in bone, screws and nails are often used.
Modern surgery is often performed through tiny openings through which a video camera and instruments are inserted. In the most modern settings, the whole battery of equipment is driven mechanically and is controlled from a computer unit where the surgeon sits. Such a setting is called robotic surgery
The surgery finishes by closing of the incisions and by wound dressing. Often the surgeon will first places tubes that goes from the inside of the surgical site to the outside, and these will remain some time during healing. The catheters drain the site for blood and fluid that leak from the tissues. They can also be used for flushing of the surgical site and to instill antimicrobial drugs.
After surgery the anesthesia is discontinued and the patient is allowed to wake up, but artificial ventilation continues some time during this process. When the patient is nearly fully awake, the ventilation is discontinued and they take out the laryngeal tube so that the patient can breath by his own.
During this time the Foley catheter may be taken out or left to remain. Some IVs, electrodes and sensors will be taken out, but at least one IV, the pulse oximeter, the blood pressure cuff and an electrode at the upper body will be left to stay some time. Also catheters for administering of local anesthesia and drainage tubes will be left to stay. It is customary to place back the clothes on the patient at this point, at least at the lower body, which provides that the patient often will not know that he has been totally naked.
When stable, the patient will be transferred to a post-operative bed unit where he will be monitored tightly for some hours before they transfer him to an ordinary hospital room. During hours and sometimes days after surgery the patient will typically be given medication to alleviate pain and nausea, and for relaxation. Pain medication will typically be achieved with opiates. For sedation and nausea treatment they mostly use diazepines like midazolam.
One will try to let the patient rise up some time as soon as possible to avoid complications due to ineffective blood flow, like blood clots. If he cannot rise up for some time, the patient may be equipped with cuffs around the legs that are constantly inflated and deflated in a wave-like fashion to ease blood flow.
At some point the rest of the IVs, the electrodes and catheters will be taken out and medication discontinued.