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Painless surgery?

Is painless surgery possible? The answer is Yes. It is possible to reduce post operative pain to negligible or none. Much orthopaedic surgery can be entirely pain free.

“Pain-less” has come to be synonymous with “pain free” surgery. It seems, also, that the term is usually interpreted as freedom from pain during the surgical procedure, with the expectation of inevitable pain in the convalescence.

 

Responsibility for pain managemment in surgery is often transfered to the anaesthetist, and that specialty has been exceptionally contributory both in development of strategies and as practicing individuals.

Unnecessary post-operative pain is often the result of surgical techniques, and the prime responsibility for minimising surgically induced pain remains with the surgeon. There is no single way to reduce pain – it is a composite of many, often tiny, technical strategies.

 

General or Local anaethesia, or both? It is  widely assumed that there is no conscious or subliminal pain is perceived whilst general anaesthesia is in place, or at least there is no conscious memory of that pain.

 

It is, however, possible that during general anaesthesia, pain is perceived subliminally and this might influence perceptions of pain following recovery from anaesthesia.

 

It should not be assumed that general anaesthesia is exactly comparable with local anaesthesia. What is known is that during general anaesthesia the parallel use of local anaesthesia reduces the markers of stress, and a “lighter” general anaesthetic is often possible.

Therefore until it is ascertained whether there is a subliminal effect of surgically induced pain during general anaesthesia which is different from that of local/regional anaesthesia, a prudent approach would be to assume that the two have different effects. Evolving from that is the concept that it might be appropriate to supplement all general anaesthesia with local/regional anaesthesia.

 

Other factors:

 

Gentle handling of tissues. Some surgeons believe, because the patient is anaesthetised, it does not matter  how roughly they confront the tissues. In their hurry or frustration tissues are yanked, crushed, spiked, shredded, burned, dried, subjected to phenol  and more. Sharp instruments are used where rounded could be used. Blunt instruments are forced. Bone is levered, hammered and filed. The problem is that once the anaesthetic is reversed those bruises, cuts and other injuries will remain for days of longer. Is it any surprise that those patients will have post operative pain? The beautiful and delicate structure with which they are working deserves the gentlest and minimum of handling irrespective of whether the patient is anaesthetised. These velnerable tissues (now not protected by intact skin) deserve to be kept moist, and washed frequently.

 

The incision.

Skin is the main organ in the perception of pain, and warrants careful handling. A single stroke incision right through the dermis is desirable. This takes skill, but is necessary to avoid “sawing” through the dermis, where the second and subsequent incisions are usually not exactly on the first, but instead parallel. This increases the cut surface substantially and leaves potentially avascular “tags”. Although these may be microscopic it is attention to this type of detail which adds eventually to the least possible pain.

 

Subcutaneous tissues. I believe that the fat should not be cut. Instead it can be easily separated bluntly, leaving the lipocytes and lysosomes intact. Cutting into lipocytes allows spillage of the contained long chain fatty acids. Post operatively these free fats will be broken down into short chain fats which are markedly inflammogenic. Another reason is that small blood vessels, which would otherwise be cut within the fat, are instead left displayed taut allowing easy cauterising. If the vessels are cut with the fat they will retract into the fat, and subsequent cauterisation will damage to the surrounding fat. The least bleeding, the least pain.

 

Diathermy coagulation. Following incision a frequent action is to rapidly cauterised with diathermy any bleeding vessel . The result is that a large surface of the wound had been damaged by burning. Instead the surgeon could wait a minute or so, washing the wound with water. Most small vessels will stop bleeding naturally, and so much tissue death is avoided.

Diathermy is frequently used on the highest available amperage. This causes a considerable radius of tissue damage beyond the target blood vessel. It is possible to use 20% or less of the available power and still have effective coagulation, particularly if the vessel is carefully separated as explained. Nursing staff, used to seeing the highest possible levels used routinely, are often astonished when low level coagulation is demonstrated to be effective.

 

Cutting diathermy. There are occasions when cutting diathermy is mandatory. However it is often used as a “convenience” since the blood vessels are cauterised simultaneously. This is to be criticised as far more tissue necrosis occurs, with more associated pain. I do not know whether ultrasound “knives” are less traumatic (and hence less painful post-operatively) but this might be the case.

 

Burning. Forceful reaming or drilling, often because of blunt instruments, produces high heat levels, with death of bone and subsequent pain. The lightest of pressures should be used (even if this takes longer), along with a cooling stream of water when possible.

 

Tourniquet use. Tourniquets often produce considerable pain by their direct pressure effect. The also produce discomfort or pain post operatively by bruising of nerve and muscle, and by the ischemia. Tourniquets, I believe, do not need to be used routinely in careful surgery and should, perhaps, be placed but not inflated until it is apparent that their benefit is specifically required. What is condemnable is to retain the tourniquet until the skin is closed. Although “convenient” and neat, this prevents the identification and haemostasis of bleeding vessels. The accumulating blood in tissues and joints is one of the major preventable causes of post-operative pain.

 

Screws are often tightened well beyond the optimal. The pain produced is indicative of continuing damage to bone. This necrosis ultimately causes the bone retaining the screws to resorb, and loosen prematurely. Tight, painful screw insertion is bad orthopaedics.      

 

Premature reduction of fractures. This produces considerable damage to soft tissues, marked post operative pain and permanent residual damage. The importance of this warrants discussion in a separate dedicated post.

 

Washing of wounds. There is no doubt in my mind that the greatest single preventer of post surgical pain is extensive washing of wounds. I routinely use at least one litre of fluid (it probably does not mater which) given by irrigating tube for the smallest of wounds – three litres for larger. I use chilled water, but I am uncertain whether this has more benefit. However, since all these factors together lead to painless surgery I do not plan to change anything.

One can speculate as to how washing works, perhaps by changes in cytokine release, and certainly by washing out isolated (dead) fat cells and fatty acids. However such speculation is not useful, since it works, which is all that counts.

In the early days of arthroscopic surgery I was told by one of the pioneers that “there is something magic about arthroscopy – there is so little pain!” There was something magic, and that was the water used in irrigation.

 

Local anaesthetic injection, usually with adrenalin to further reduce bleeding. This should be injected sub-cutaneously (do not put more holes in the skin), Careful planning of spacing will reduce the number of injection sites to the minimum, and the smallest possible gauge of needle will all help to reduce post-operative pain.

 

Closure. Fat sutures.

There is no point whatever in using fat sutures. Fat is not a structural tissue, and instead has the properties of a fluid. Suturing strangle the fat, and with its death a release of inflammogenic material. Unnecessary foreign material is implanted. Necrosis and foreign matter increases the risk of infection. This is demonstrated in meat which first becomes rancid in the fat. Further, the flow properties of the fat are restricted, with distortion of the aesthetically important contouring produced by fat. One common argument for suturing fat is that “It closes the dead space and allows accumulation of blood”. This is nonsensical. The integument enclosed a certain volume before the surgery and this volume would be the same for the fat post surgery. The integument will close the dead space, unless significant fat has been removed. If that occurs then vacuum drainage should be used. It also goes without saying that meticulous haemostasis is expected.

 

Closure. Skin handling. Toothed forceps are routinely used to hold skin to suture. This produces multiple micro punctures in the skin, which can cause considerable pain. Imagine putting scores of these crush-punctures into your own skin. Would it be a surprise if there was pain for days after? Instead I use small skin hooks in the subcutaneous surface.

 

Closure. Sutures. Tight sutures (which they often are) are a major source of post operative pain. Sutures which pinch the wound damage the skin

and cause tissue necrosis. A standard way to arouse the deeply unconscious is to pinch the skin, which illustrates the intensity of this pain.

Sutures are necessary at times, particularly for everting curved or sinuous incisions (straight incisions, apart from the midline, are the stigma of the amateur).

Sutures can often be substituted by staples (which do not crush the skin and are surprisingly painless, even in the sole of the foot) and, probably the best, adhesive closure strips. Adhesive should be applied to the skin first, and the longest possible strip use. This allows maximum mechanical strength, and distributes the force over a larger area of skin and so reduces discomfort further. The eventual scar is always better for using closure strips, and wound infection greatly reduced.

 

Closure. Alignment of skin edges. The ability of skin to distend varies with site and the direction of stretch, comparable to fabrics like Lycra. To return the two edges of the incision precisely (to within at most a millimetre) seems to allow less discomfort and a better scar. This is not easy, because of the variable stretch, and the only way I know is to make small markings, at most 1cm apart, close to the incision, to assist alignment. Accurately apposed skin seems to reduce pain.

 

Dressings. The design of dressings that remain whilst required, are least obstructive to function, and can be removed with minimal pain, is an art in itself.

 

 

Less-pain surgery is good surgery, not only because it is compassionate. It also means there is less damage and death of tissues. This will be rewarded with less post operative infection. [Washing wounds alone has long been recognised as reducing infection]. There is also evidence that less-pain surgery reduces the incidence of deep venous thrombosis, and shortens convalescent times.

 

Rapid surgeons are often regarded as “good surgeons”. This perplexes me. Careful surgery takes longer, and this will be rewarded with less pain and less chance of infection. Are the best portrait painters the fastest?

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2 Responses

  1. After a THR surgery 3 months ago. I have a lot of pain on the heal. I can’t put full weight on thr leg as a result. The rest of the leg is fine. Even the hips have no problem. What is the cause of the pain?

    • The heel is a complicated structure. There are a number of attachments such as the plantar fascia and the Achilles tendon. There are also structures running past it – a number of tendons, and it is a route for nerves and blood vessels. Things can go wrong with the bone itself – an occult cyst in the calcaneum might now have become symptomatic. The joints between the calcaneum (heel bone) and other adjacent bones are potential sources of pain. It is also possible that irritation of the sciatic nerve, where it routes past your total hip replacement, could also give the perception of pain in the heel.
      Your pain could be arising from any of these.
      This partial list is not designed to confuse you (which it might have done) but to demonstrate the complexities of this very “busy” anatomical area. You need professional orthopaedic expertise to get your answer.

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