'Do no further harm'; safe surgery starts with a surgeon making the right decision when to operate and when not to operate. To come to this decision the expected benefits and possible risks of the treatment options should be weighed.

The safety and efficacy of care delivered to surgical patients can be improved by paying attention to several key aspects, including the use of a safe surgery checklist, ensuring safe anesthesia, maintaining sterile conditions, implementing measures for sterile conditions and infection prevention and control (IPC) and assessing the patient’s general condition.

Surgery is teamwork - Optimizing communication and collaboration is crucial to prevent errors and adverse events.

Safe surgery checklist

The WHO Surgical Safety Checklist² has led to a significant reduction in both morbidity and mortality and is now used by most surgical providers around the world.

The WHO Surgical Safety Checklist² is an example of a time out procedure that should be performed for every surgery. It was developed to decrease errors and adverse events, and to improve teamwork and communication in surgery. Create your own safe surgery checklist to decrease errors in your setting. Items that can be included are:

1 Confirm patient identity - Verify the patient’s name and identification details.

2 Anticoagulation status - Review and address any anticoagulation medication the patient may be on.

3 Confirm known allergies - Confirm any known allergies to avoid adverse reactions.

4 Fasting - To reduce the risk of pulmonary aspiration, encourage adults and children to drink clear fluids (including water, pulp-free juice and tea or coffee without milk) up to two hours before elective surgery and prohibit solid food for six hours before elective surgery.

Following trauma, fasting will not secure emptying of the stomach, so always treat these patients as if the stomach was full¹.

5 Describe intended procedure and side - Verify the exact procedure planned to ensure everyone on the team is aligned. Mark the correct limb preoperatively in confirmation with the patient. This shows the correct location even if the patient is repositioned during surgery.

6 Blood loss - Risk of big amounts of blood loss and anticipated actions.

7 Essential equipment - Ensure all necessary equipment is available and functional. Include the necessity of intra-operative imaging if needed.

8 Patient position - Confirm the patient positioning for the procedure.

9 Antibiotic prophylaxis - Confirm, if needed, the type, dosing and moment of antibiotic prophylaxis to be given.

10 Anesthesia - Describe relevant co-morbidities, expected critical events and the type of anesthesia given.

WHO Surgical Safety Checklist²

Recommendation: Edit the checklist to your local practice. Using the example of the checklist shown above, without adapting the checklist to local needs is a common mistake. The process to develop a checklist for your facility should include all relevant team members, using the local language and covering the relevant items in that particular setting. The WHO website shows steps to implement the WHO Surgical Safety Checklist in a facility.

Safe anesthesia

'No safe surgery without safe anesthesia'.

There is an urgent need for further enhancements in anesthesia delivery and surgical care infrastructure in low-resource settings. Safe anesthesia administration in low-resource settings demands innovative strategies to overcome challenges like limited equipment and well trained staffing. 

Patients undergoing surgery in low-resource areas confront two to three times increased mortality risk compared to those in high-resource areas.³

The main types of anesthesia are general anesthesia, regional anesthesia - including loco-regional nerve blocks, local anesthesia, and sedation

General anesthesia

In general anesthesia the entire body and brain are put to sleep. The patient is unconscious, pain-free, and not moving.

Requirements for general anesthesia include: 

• Qualified personal - Trained in administering and monitoring anesthesia (anesthesiologist, nurse anesthetist, or anesthesia provider with adequate training).
• Essential equipment - The minimum equipment required for safe surgery is listed in the table below.
• Essential drugs
• Safe environment

Category	Minimum Equipment
Airway Management	- Bag-valve mask - Oxygen source & tubing - Oral/nasal airways - Suction device & catheters - Endotracheal tubes (various sizes) - Laryngoscope with blades & spare batteries/bulbs
Breathing System	- Basic anesthesia circuit (e.g., Mapleson C or Bain system) - Functional anesthesia machine (if available)
Monitoring	- Pulse oximeter - Blood pressure cuff - Stethoscope - Capnography (if available) - ECG (if available)
IV Access	- Intravenous cannulas and fluids
Emergency Equipment	- Defibrillator (if available) - Resuscitation drugs (e.g., adrenaline, atropine)

Anesthesia providers in low-resource settings often administer ketamine, which requires less monitoring and is less susceptible to shortages. However, clear protocols are required on when and how to use ketamine because it's use is not without risks.

Regional anesthesia techniques

Regional anesthesia techniques, such as spinal anesthesia, demand fewer medications and equipment compared to general anesthesia. These techniques diminish reliance on general anesthesia drugs and ventilation support. Spinal anesthesia are used for procedures below the umbilicus. The duration of spinal anesthesia can vary depending on the agent used:

• Prilocaine – approximately 1 hour.
• Bupivacaine – 3 to 4 hours.
• Opioids - in spinal anesthesia may include low dose opioids for enhanced analgesic effect.

Loco-regional techniques, also known as nerve blocks, are suitable for many orthopedic procedures. They provide effective anesthesia that can last up to 24 hours. The type of nerve block depends on the operation and the innervation of the area involved.

The administration of most nerve blocks requires the use of ultrasound guidance and the expertise of an experienced anesthesiologist to ensure accuracy and safety.

Online resources such as the Nysora website⁴ provide an overview of possible nerve blocks for different types of surgery.

Local Anesthesia (LA)

• Area - A small, specific area of the body is numbed.
• Awake - The patient is fully awake.
• Minor procedures - Only used for minor procedures (e.g., skin suturing, minor excisions).

Sedation

The patients receives sedation and pain control, but breathes on their own.

Sterility & Infection prevention and control (IPC)

Infection is a common complication of any surgical procedure, and care should be taken to prevent it. Performing surgery in a sterile environment and infection prevention and control are cornerstones of practicing safe surgery.

Modern surgical and aseptic techniques have reduced the prevalence of surgical site infections (SSIs). However, still in low- and middle-income countries, one-third of patients undergoing surgical procedures may be affected by an SSI. 

The following recommendations come from:
The WHO Surgical Site Infection Guideline⁶
The American College of Surgeons’ Strong for Surgery program⁷
The BAPRAS Open fracture guideline⁸

Preoperative measures

• Antibiotics - In patients with acute open fractures, administer antibiotics as early as possible upon hospital arrival, preferably within one hour. If surgery is indicated, administer surgical antibiotic prophylaxis within 120 minutes before incision, taking into account the antibiotic’s half-life.
• Wound dressing - Dress wounds temporarily with clean water soaked gauzes until the patient is taken to the operation theatre.
• Smoking - Encourage the patient to stop smoking: quitting smoking before and after surgery decreases risk of adverse events and SSIs.
• Blood sugar - Control blood sugar according to the local hospital protocol. Hyperglycemia doubles the risk of SSIs.
• Immunosuppressive agents - If immunosuppressive agents are used, do not stop them before surgery.
• Nutrition - In case of malnourished patients undergoing major surgery, consider the administration of oral or enteral nutrient-enhanced nutritional formulas. If time allows, preoperative optimization of nutritional status should have priority. 
• Hygiene - The patient should bathe or shower before surgery, with plain or antimicrobial soap.
• Sterilization of surgical instruments - An autoclave is a machine that sterilizes items using steam under pressure. Maintenance schedules and trained staff for proper use of an autoclave are paramount for sterility of surgical instruments. Low-cost autoclaves intended for low-resource settings are available from various suppliers, such as the EcoClave from MedAid.⁵

Intraoperative measures

• Well-organized surgical setup - There should be specific areas for sterile and non-sterile equipment, and clear protocols for handling instruments and supplies. Comprehensive training for all surgical team members is advised.
• Hair removal - In patients undergoing any surgical procedure, hair should either not be removed or, if absolutely necessary, should only be removed with a clipper right before surgery.
• Skin preperation - Use alcohol-based antiseptic solutions based on chlorhexidine gluconate for surgical site skin preparation.
• Surgical hand preparation should be performed with antimicrobial soap and water or alcohol-based handrub.
• Drapes and gowns - Use either sterile disposable non-woven or sterile reusable woven drapes and surgical gowns during surgical operations.
• Fluid - Use goal-directed fluid therapy.
• Body Temperature - Maintain normal body temperature. Cover with warm blankets as soon as the patient enters the OR; the first 10 minutes are crucial for body temperature maintenance. 
• Debridement - Early and thorough wound excision is essential, with wound extension according to the fasciotomy lines if necessary. 
• Irrigation after debridement - Irrigate the wound after debridement in the operating theater, not before. Irrigation should be performed with minimum 3L (up to 12L in gustilo-anderson grade 3 open fractures). Although in most guidelines normal saline is advised (not soap), advantage over clean tapwater is uncertain.⁹ High-pressure pulse lavage should be avoided.
• Irrigation before closure - Consider irrigation with Povidone-Iodine 10% solution before closure. After that, rinse with saline for tissue viability.

'The solution to pollution is dilution' - The phrase refers to the high-volume of irrigation used to wash out bacteria, blood, and debris from surgical wounds to prevent infections.

Postoperative measures

• Prolonged antibiotic use - There is no good evidence that in general prolonging surgical antibiotic prophylaxis will prevent SSIs.
• Wound dressing - To prevent SSIs advanced wound dressing is not superior to standard wound dressing for primarily closed surgical wounds.