Risks of surgery and anaesthesia

Consent for an operation and risks of anaesthesia and surgery

Having an operation is a big step for patients and their families, and it can be difficult to make the decision to go ahead. This often accompanied by some worries about the risks of surgery and anaesthesia, and these risks have to be weighed up against the benefits of the operation itself. This page covers consent for surgery, patient risk factors, risks of surgeries and the risks of general anaesthesia, with some useful links further down.

Many of the problems which we treat in ENT practice for adults and children can be managed medically or simply watching for natural improvement, without requiring an operation at all. However, in some cases, the symptoms are significant enough to impact on everyday life and they can't be managed just with medical treatment or observation. In these circumstances, we may consider surgery, with an operation specifically tailored to the particular patient's needs. The decision to go ahead with surgery is one which we surgeons take in partnership with patients and their families, having considered other options already, and making it clear why surgery is the best option. We will also clarify why other management options (medical treatment, observation) are less likely to be helpful, and also the likely outcome in terms of ongoing symptoms if we don't go ahead with surgery at all. This will depend upon the specific condition and type of surgery in each case.

It is really important that patients and their families are never under any pressure to make these decisions, and they are free to ask questions at any stage and to change their mind freely, right up to the date of surgery itself.

As doctors, we are always much happier that our patients and families feel completely relaxed in terms of decision-making, and to help with this process we provide plenty of information (for example in the FAQ section of this website). We can arrange follow-up appointments to have further discussions. There is also always the option to ask for a second opinion, and we can direct you sensibly for this if needed.

Things to consider

In terms of risks of having an operation, we consider:

The patient themselves (age, medical history, allergies and other issues)

The type of surgery

The risks of anaesthesia

All of this can then be weighed up against the alternative of not having an operation, and continuing with the existing symptoms.

Patients

Patients of different ages, sizes and medical history will have different risks of having an operation, particularly relating to having a general anaesthetic. We will aim to ask sensible questions in clinic, in terms of any prematurity, birth history, medical difficulties in early in life, admissions to hospital, other operations in the past and any complications with these, use of any medications and allergies to foods and medicines. We will also ask about any family history of problems with general anaesthesia or other medical problems which might be relevant. Please try and tell us about any of these issues as early as possible, if you think that the information might be relevant in any way.

Medical problems

Anaesthetists will categorise patients according to risk factors for difficulties and complications with general anaesthesia. This is known as the American Society of Anaesthesiologists classification (ASA):

ASA class I

A healthy patient, fit and well for normal activities, with no significant medical problems, of normal weight, no smoking and minimal alcohol use.

ASA class II

A patient with an underlying medical condition which is well controlled, for example asthma or diabetes, a previous heart problem which they were born with which is now corrected, moderate use of cigarettes or alcohol, for example, or being moderately overweight, and this also applies to patients with an underlying syndrome, as this will be present lifelong.

ASA class III

A patient with a more significant medical history, such as poorly controlled diabetes or high blood pressure, and uncorrected heart defect, very severe obesity, kidney failure, metabolic disease.

ASA IV

A patient with very severe medical problems, for example someone who is already in intensive care.

Patients undergoing anaesthesia and surgery are classified in this way so that we can assess risk of having an operation. The higher the class, the more risky it is surgery under general anaesthesia.

Patient age

We also need to consider patient age when making these risk assessments.

Young children will have changing physiology and metabolism as they progress from newborns to infants, toddlers and then school age children and onwards.

Babies in the neonatal period within 28 days of birth are very delicate, and are managed by anaesthetists and surgeons who are experienced in looking after patients at this very young age.

Following on, children under six months of age are still difficult to manage, and this becomes easier as they get older.

In the same way, very elderly and frail patients may have higher risks relating to their age than younger adults, even when we don't consider other medical problems.

As such, we need to be as certain as possible whether or not surgery is definitely needed in patients at particular ages, and whether it could be delayed or whether medical management or simple observation might not be better alternatives.

Surgery

The risks of the operation itself in terms of surgical complications will vary according to the particular operation and the technique used. For example, there are specific risks of tonsil removal, insertion of grommets, airway endoscopy and so on. These are all explained in detail under the patient information section of the website, accessible via the FAQ link. Please read through the relevant information for you or your child when considering surgery, and before the operation itself. This will form the basis of the consent form which we will ask you to sign on the day of surgery.

The choice of surgery and the methods which we use in each case will together aim to give the best possible result with the most straightforward recovery afterwards and the lowest chance of complications. In many cases, the operations themselves are very gentle, most of the time with discharge on the day of surgery, and often allowing return to school or nursery within 24 to 48 hours, but there are some instances where a longer recovery period is needed. This will vary according to the different type of surgery.

In general, the types of complications of surgery which we will discuss are:

Pain – this will vary considerably according to the different type of surgery and method used. For example, following insertion of grommets or removal of the adenoids, pain can be minimal, with paracetamol and ibuprofen given only as required. Other operations, such as tonsil removal, are likely to produce more pain afterwards, requiring regular use of paracetamol and ibuprofen, and occasionally something stronger, such as morphine.

Bleeding – again, this will vary according to the different type of surgery. For example, after surgeries for the ears, such as insertion of grommets or eardrum repair, some oozing of blood may be seen, which will generally stop on its own. Other operations, such as tonsil removal, may associated with relatively heavy bleeding after surgery, with the need to return to hospital. Very occasionally, another procedure under general anaesthetic to stop bleeding, or even a blood transfusion – but this is very rare. Bleeding of this type can happen within two weeks of surgery, so it's important to be aware of this and to let school or nursery teachers or other caregivers know that this can be an issue, and to seek medical attention if this is the case.

Infection – sometimes, operations can result in infections afterwards, for example smelly discharge from the ears after ear surgery, a temperature a few days afterwards or a wound infection. In the head and neck, the blood supply is very good, and it's therefore very unusual to get infections in the mouth or throat after tonsil and adenoid surgery, as these areas heal very well. However, these healing areas are commonly colonised with bacteria, and may be white and very smelly, despite not being infected. When children have high temperatures or are unwell, this may be the result of parallel viral illness, given that children can have coughs and colds very commonly, and this includes around the time of surgery.

Breathing problems after surgery- some of the patients undergoing ENT surgery will already have significant breathing problems which are the reason for the operation itself, such as heavy snoring or sleep apnoea. After surgery, they may have more mucus and saliva, which can affect their breathing, sometimes needing oxygen, medication and suctioning in the recovery room and the ward. Occasionally, an overnight stay is needed, either planned in advance, or unexpectedly, for example if children have a viral illness in parallel.

Injury to the lips, teeth and gums – when we operate in the mouth, for example when removing the tonsils, we use a spacer to hold the mouth open and we also use instruments which pass in and out of the mouth, past the teeth. There is a risk of injury to the teeth, lips and gums. This is usually only a very minor issue, and it is very unlikely that the teeth will be permanently damaged, for example. Please let us know if you or your child having the surgery has any history of loose or broken teeth, or indeed any existing ulcers or wounds around the mouth or lips.

Injury to the skin or eyes - we often wrap up the head and face during surgery to protect them from being injured by our instruments. Sometimes, holding a facemask or removal of a dressing, etc., can leave a red mark on the skin, which will usually fade within a few days. More significant injuries to the skin or eyes are very rare, and we take great care to avoid these happening.

Persistent or recurrent symptoms – although many patients having surgery are completely cured, with excellent results, sometimes, despite an operation, patients may still have some degree of symptoms: for example ongoing breathing difficulties or hearing problems (depending upon the reason for surgery). These are persistent symptoms, which have continued. Alternatively, some patients may have a very significant improvement in symptoms, which gradually reduces with time and the symptoms come back. These are recurrent symptoms. Ongoing symptoms might require another operation or medical treatment in the future.

As discussed before, all of these risks have to be weighed up in the case of each individual patient, bearing in mind their age, medical history and other risk factors, and thinking about the severity of their symptoms, whether medical treatment or observation could be a good alternative to surgery, and what would happen without treatment.

General anaesthesia

For most surgeries in young children, and for many surgeries in adults, general anaesthesia is needed. This is provided by a Consultant Anaesthetist, who will have a great deal of experience in managing patients of this type and having these sorts of surgeries. They also have the benefit of using state-of-the-art equipment and medicines to allow patients to have surgery without any pain or awareness, with minimal anxiety and with minimal risks of any complications.

There is an excellent video which covers the process of anaesthesia here.

Before surgery, patients and their families may be very anxious, and in the clinic and on the day of surgery we will make every effort to answer questions and to make the situation as relaxed as possible. It is often really helpful to bring close family members/ parents, favourite toys, books or other activities, as appropriate. We will also try to advise you beforehand about when it is reasonable to eat and drink before the operation, aiming to have the stomach free from food or milk at the time of the operation, because otherwise stomach contents and acid can be burped up when the anaesthetic is given. 

In general, the recommended fasting times before surgery are:

Food and milk (including cow and formula milk), tea, coffee: until 6 hours before surgery

Breast milk: until 3 to 4 hours before surgery

Clear fluids (water, Ribena, diluted orange squash): until within 1 hour of surgery. If there is any doubt, please avoid other drinks, such as real fruit juice, coconut water, coffee, tea, etc.

We will always let you know these fasting times before surgery, so that you can plan for the day.

Pre-medication for anxious patients

Additionally, for particularly anxious patients, we can offer a premedication medicine (for example midazolam) 20 to 30 minutes before the anaesthetic is given, which can reduce anxiety or stress, and it also means that the patient won't remember what has gone on.

Anaesthesia

Patients are anaesthetised before an operation in the anaesthetic room next to the main operating room. They are welcomed in by the Consultant Anaesthetist and their Anaesthetic Assistant Nurse (ODP), who will check the consent form, patient details and ask about any allergies or relevant information.

The anaesthetic medication which is used to start the process of anaesthesia can be given either as gas, via a face mask, which is often done in young children, or alternatively with a cannula in a vein on the back of the hand, after applying some numbing cream to make insertion of the cannula more comfortable. This is usually considered in older children and adults, who will tolerate this better. The choice will have been discussed in advance.

Once the patient is asleep, a breathing tube or device will be inserted into the airway to feed in oxygen and anaesthetic gas, and the patient is then moved into the operating room for the operation to be undertaken. All of the vital signs (temperature, pulse, blood pressure, oxygen levels) are measured throughout the operation, to make sure that they are all within safe limits, and painkillers are given during the operation, which will still be effective afterwards.

At the end of the procedure, the anaesthetic medication is reduced down, and the patient wakes up and is taken to the recovery room, where they have oxygen and painkillers, and they may stay there for 20 to 30 minutes before coming back to the ward.

Depending on the type of operation, discharge home is usually possible within a few hours, but sometimes an overnight stay is required, which has either been planned in advance (for example a very young child, complex surgery or living far away), or if there have been any difficulties around the time of surgery, for example the need for oxygen or prolonged pain relief afterwards.

When leaving Hospital, you will receive detailed instructions in terms of the recovery process, contact details in the event of any problems and also medication for the post-operative period. We are always very happy for patients or their families to get back in touch with any queries. We will also explain follow-up arrangements.

Risks of general anaesthesia

Patients and their families are often worried particularly about the risks of general anaesthesia. It is really important to know that this is typically a very safe process, delivered by expert doctors and their assistants, with modern equipment and with the latest medicines, which together make the anaesthesia very safe and effective.

However, there are some particular associated risks, and these have been described really clearly by the Royal College of Anaesthetists, who are responsible for anaesthetic practice in the UK. They have looked at some different areas, looking at complications which come up relatively commonly, occasionally, rarely and very rarely. These are summarised below, covering both children and adults having a general anaesthetic. Please click here for a link to the document.

Very common (more than one in 10 cases)

Sore throat, because of the need to insert a breathing device, which will normally settle down within 24 to 48 h

Agitation on waking up from the anaesthetic, with some distress, which is usually settles down within 60 to 90 minutes

Nausea and sickness, which we try to reduce by minimising fasting and also using anti-sickness medication

Temporary changes in behaviour, for example some anxiety, sleep problems for bedwetting soon after surgery

Common (between one in 10 and one in 100 cases)

Minor injury to the lips, throat or tongue from insertion of the breathing tube or airway device by the anaesthetist

Discomfort, bruising or swelling at the site of the cannula in the hand or arm

Uncommon (between one in 100 and one in 1000 cases)

Breathing problems requiring medications, nebulisers or prolonged use of oxygen after surgery, and perhaps an overnight stay

Damage to the skin (from pressure when lying flat or from medication leaking out into the skin around the cannula)

Rare (between one in 1000 and one in 10,000 cases)

Need for an unplanned intensive-care admission (the risk is higher for children under one year of age)

Injury to the eye (for example a scratch when asleep)

Damage to the teeth, for example a chip or crack or loosened tooth afterwards

Very rare (between one in 10,000 and one in 100,000 cases)

Severe allergic reaction/ anaphylaxis or another drug reaction – one in 40,000 cases

Awareness during anaesthesia (being aware of what is going on) – one in 60,000 cases

Long-term disability (brain injury from oxygen depletion, severe nerve injury) – less and one in 100,000 cases

Death as a result of anaesthesia-between one in 100,000 and one in 1 million cases

Summary

This page has covered the various issues to consider when thinking about having surgery for you or your child. This includes thinking about whether or not surgery is needed, possible alternative treatments, the chance to ask further questions, to look for a second opinion or to change your mind at any time.

The decision should be made freely and in partnership with your surgeon.

Risks of surgery will vary according to the age and medical history of the patient, and also depending upon the type of surgery undertaken.

There are also risks associated with general anaesthesia.

Serious complications are thankfully very rare, but it is important to be aware of these and to consider them when making a decision about surgery.