Pre-operative assessment for elective hernia repair
PLAB 2 & PRES 3 · surgery · medium · 8 minutes
Candidate brief
You are an FY2 doctor/SHO in the pre-operative assessment clinic. Mr Peter Walsh, 59, is scheduled for elective laparoscopic inguinal hernia repair in 3 weeks. Assess his fitness and perioperative risks, identify any optimisation required and explain the preparation plan. You are not being asked to obtain consent for the operation. Verbalise any examinations, investigations or referrals you would undertake.
What examiners look for
Pre-operative assessment identifies anaesthetic and surgical risks, optimises health and provides a safe individual plan. It is not the same as consenting the patient for surgery. Assess functional capacity. Ask whether the patient can climb stairs or perform ordinary activity without chest pain, limiting breathlessness or other symptoms. Review medical conditions, previous surgery and anaesthesia, allergies, airway, smoking, alcohol, nutrition, frailty, sleep apnoea, bleeding risk, VTE history and home support. Reconcile all prescribed, over-the-counter and herbal medicines. Do not tell patients to stop all medication or make unsupported changes. SGLT2 inhibitors such as empagliflozin need an agreed interruption and restart plan around surgery because fasting and surgery increase the risk of ketoacidosis. Follow the local diabetes and anaesthetic protocol. Order tests according to the procedure, ASA grade and comorbidities. Do not routinely request chest X-ray, coagulation tests, echocardiography or urine dipstick without an indication. Assess and optimise modifiable risks, including smoking, alcohol, diabetes, blood pressure, anaemia, nutrition and physical fitness. Do not independently declare a patient fit when significant symptoms or abnormal findings require senior anaesthetic or specialist review. Provide written instructions about fasting, medication, admission, transport, postoperative support, pain relief, mobilisation and blood-clot prevention.
Guideline references
- https://www.nice.org.uk/guidance/ng45
- https://www.nice.org.uk/guidance/ng45/chapter/recommendations
- https://www.nice.org.uk/guidance/ng180
- https://www.nice.org.uk/guidance/ng180/chapter/recommendations
- https://www.nice.org.uk/guidance/qs216
- https://www.nice.org.uk/guidance/qs216/chapter/quality-statement-2-assessment-of-perioperative-risk
- https://about.hse.ie/publications/hcp-model-of-care-for-preassessment-services/
- https://about.hse.ie/api/v2/download-file/healthcare_professional_publications/Model_of_Care_for_Preassessment_Services.pdf
- https://www2.healthservice.hse.ie/organisation/national-pppgs/national-policy-and-procedure-for-safe-surgery/
- https://www.gov.uk/drug-safety-update/sglt2-inhibitors-monitor-ketones-in-blood-during-treatment-interruption-for-surgical-procedures-or-acute-serious-medical-illness
- https://www.nhs.uk/tests-and-treatments/inguinal-hernia-repair/
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