Introduction

Surgical site infections (SSIs) are just one of the many complications that may follow a surgical procedure. A study conducted from 2019-2020 found the rate of SSIs in Medicare and Premier populations to be 2%, with the rate of SSIs in patients who received abdominal surgery at approximately 5%. The cost of these infections was estimated to be over $18,000 incrementally.¹ In addition to SSIs, other postoperative complications may include the following²:

• Deep vein thrombosis or pulmonary embolism
• Shock or hemorrhage
• Reactions to anesthesia
• Pulmonary complications and difficulty breathing
• Temporary problems with urine retention

Because of the many risks surgery poses, patients and non-surgeon clinicians tend to be apprehensive when assessing treatment options. In addition, patients may harbor concerns about the severity of postoperative pain.³ However, even procedures such as reconstructive plastic surgery can be integral for achieving best outcomes, including restoring functionality in those with congenital disabilities or deformities.⁴ For these reasons, many surgeons are adopting the practice of prehabilitation to minimize risk and ensure a patient’s ability to recover from a procedure.

According to the American College of Surgeons, prehabilitation is the practice of “improving the functional capability of a patient prior to a surgical procedure so the patient can withstand any postoperative inactivity and associated decline.”⁵

Our team had the chance to interview Dr. Lisa Gould about her WoundCon session, "Prehabilitation – What Should I Do Before My Patient Undergoes Reconstructive Plastic Surgery?” Dr. Gould discusses the wide variety of patients she sees as a wound surgeon and how she applies prehabilitation to wound care patients.

1. What are you hoping to cover in this session?

   My goal for this session is to emphasize that it requires a team effort to get patients with wounds ready for major surgeries. I intend to highlight how the principles of prehabilitation, usually used for elective general surgery patients, can be adapted to improve outcomes for even our most complex wound patients.

2. What inspired you to create and present on this topic?

   The American College of Surgeons has really been pushing “prehab,” which evolved into Enhanced Recovery After Surgery (ERAS). I am the wound surgeon for my hospital and treat a wide variety of patients and problems, including older adults who are often frail and have multiple medical problems, younger patients with severe infections, diabetics with chronic infections, and people with spinal cord injury/disease who have non-healing pressure-related wounds. I wanted to see if that program is applicable to the patients I treat.

3. Why do you feel like Prehabilitation is a crucial topic for clinicians?

   There is a lot of misunderstanding about surgery. I have heard wound clinicians and non-surgical clinicians discouraging patients from having surgery. Patients, especially our older adults, tend to be afraid of surgery, especially anesthesia. This is a team sport. Therefore, it is important for all clinicians to understand when surgery is appropriate and how to prepare the patient medically to have a safe surgery.

4. What do you feel are the leading innovations in the field regarding prehabilitation?

   I think prehab itself is still considered an innovation. Most recently, the concept has entered the field of cancer care and cancer surgery. New literature supports that even a short period of prehab, including in-patient prehab, may be beneficial. For patients at home, the implementation of digital support that includes customizable and personalized care pathways, remote monitoring, and decision support can increase access, help personalize the program, improve adherence, and increase collaboration between caregivers.

5. What are some common roadblocks that you’ve seen when it comes to a successful outcome for patients? What are some common roadblocks for clinicians?

   Patients with wounds do not fit the mold of the typical prehab program. Many cannot ambulate or do prescribed exercises, which negates one key component of the usual approach. Physical Therapy/ Occupational Therapy (PT/OT) is overlooked for these patients because people forget that being bed or chair bound does not mean that these patients cannot be active. I try to emphasize to my older or spinal cord-injured patients that they can do things, such as upper extremity exercises and leg lifts in bed. These improve their strength and will increase their heart rate. Also, the emphasis on emotional support and stress reduction, which includes caregivers, is an area that clinicians tend to overlook. It can help with the surgery itself and definitely helps when post-op care is prolonged and difficult. Nutrition is also a major component of prehab, and nutritional supplements are expensive, rarely covered by insurance, and sometimes not very palatable. We need to teach patients that food is medicine and will go a long way toward improving their recovery and healing.

6. What one thing do you feel clinicians can do tomorrow to improve their understanding of these practices when it comes to prehabilitation?

   Increased awareness of the concept of prehab will go a long way toward acceptance. Although there are 4 basic parameters—nutritional supplementation, smoking cessation, physical and cognitive exercise, and stress reduction—it’s important to understand that the overarching goal of prehab is to improve the patient’s functional capacity for a surgical procedure. Therefore, these 4 parameters can be (and need to be) adapted to fit the patient.

7. What do you hope clinicians will take away from this session?

   I hope they will examine their practices and identify at least a few patients who would benefit from prehab with an emphasis on nutrition, edema control in preparation for surgery, and stress reduction. See how it goes and talk to your surgeons, emphasizing that the goal is to achieve better outcomes. That is pretty hard to resist.

Conclusion

Prehabilitation prepares patients for operations and requires the aid of a multidisciplinary team.⁶ It mitigates risk factors before the procedure rather than peri- or postoperatively. Dr. Gould uses the lens of reconstructive plastic surgery to explore this innovation's uses across broader patient populations.

References

1. Hou Y, Collinsworth A, Hasa F, et al. Incidence and impact of surgical site infections on length of stay and cost of care for patients undergoing open procedures. Surgery Open Science. 2023;11:1-18.https://doi.org/10.1016/j.sopen.2022.10.004
2. WoundSource Practice Accelerator. Preventing Postoperative Complications. WoundSource. Published September 30, 2020. Accessed January 26, 2023. https://www.woundsource.com/blog/preventing-post-operative-complications
3. Blondeel P. The perpetual changing paradigm in reconstructive surgery: Developing a vision for the future. J Surg Reconstruction. October 17, 2022; 77:179-189. https://doi.org/10.1016/j.bjps.2022.10.038
4. Ustunel F, Erden S. Evaluation of Fear of Pain Among Surgical Patients in the Preoperative Period. J PeriAnesthesia Nurs. 2022;37(2):188-193. https://doi.org/10.1016/j.jopan.2021.02.003
5. Strong for Surgery: Prehabilitation. ACS. Accessed January 25, 2023. https://www.facs.org/for-patients/strong-for-surgery/prehabilitation/
6. Durrand J, Singh SJ, Danjoux G. Prehabilitation. Clin Med (Lond). 2019;19(6):458-464. doi:10.7861/clinmed.2019-0257