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  There are several valuable benefits of accurate preoperative planning including improved understanding of the procedure, communication of logistics and equipment needs, elimination of avoidable delays for equipment, and improved outcomes

  
  
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  A preoperative plan includes a surgical tactic, or step by step plan for the operation that allows the surgeon to think through the operation which can improve operative efficiency and identify unanticipated problems

Preoperative planning can prevent intraoperative delays, confusion, and errors, leading to improved patient outcomes. Thinking through the sequential steps of an operation allows a surgeon to identify possible unanticipated problems and to develop contingency plans for achieving a successful outcome.

No surgeon goes to the operating room planning to fail, but many surgeons go to the operating room failing to plan. Preparation of a carefully thought-out preoperative plan offers many advantages for the surgeon, the operating room team, and the patient. Planning provides several benefits for the surgeon, including decreased stress during operative cases that go smoother and faster. The operating room team will be better prepared with all necessary equipment, and is more likely to view the surgeon as a competent and dependable surgeon with whom they enjoy working. The direct benefits of this preparation for the patient are improved outcomes and increased safety.

The value of preoperative planning has long been recognized in orthopedic surgery, but it has become increasingly important as the technical complexity of procedures and equipment has expanded. While uniformly believed to be beneficial, the actual practice of preoperative planning is less than universal. In a survey assessing the perceived importance of preoperative planning, 94% of 34 consultants and 100% of 25 trainees considered it to be important in trauma cases, but only 50% of consultants and 48% of trainees reported that they routinely performed preoperative planning of their trauma cases.¹

As a surgeon’s experience increases, preoperative planning tends to become less formal, especially for lower complexity cases. While every operative case does not require the same type of detailed plan, every operation will benefit from some sort of plan. One of the most important aspects of preoperative planning is the advance stepwise thought process that is essentially a dress rehearsal of the operation. This cognitive part of the process is often the most important part of the planning process.

A preoperative plan is also helpful in communicating with the operating room team the surgeon’s plans and the team members’ necessary roles. In addition to the required instruments and implants, it is also helpful to identify which additional items might be needed and should be kept on standby. For example, if prior hardware needs to be removed, it may be necessary to have broken screw removal instruments available if you encounter difficulty with the planned hardware removal. Identifying the necessary equipment is especially important for surgeons who operate at more than one facility, as some equipment may be readily available at one facility but need to be brought in specifically for the case at another facility. Communicating with the OR staff regarding the necessary equipment is also important if another surgeon operating simultaneous in a different room is planning to use the same required equipment.

With the advancement of AO principles of fracture management, preoperative planning became an essential element of surgical preparation for fracture cases. Preoperative tracing of fractures and use of acetate templates were popularized through AO instructional courses.

The term surgical tactic, which describes a step-by-step guide to the operation, has been attributed to Maurice Müller.² This is especially important in operations in which one step must precede a following step. When writing out a step-by-step surgical tactic, it is important to remember that too much detail can be just as detrimental as too little detail. The surgical tactic needs to contain the key steps in the operation, but should not become lost in minutiae or sacrifice clarity for thoroughness.

The surgical tactic should include the planned patient position and surgical approach. You may also wish to note pertinent anatomy and specific structures at risk. Also included is the planned reduction technique, such as direct open reduction using a reduction forceps, or alternatively an indirect reduction using a universal distractor device. The next key element of the surgical tactic is the selection and positioning of the planned internal fixation implant. For plate fixation, the type and order of screw insertion should also be considered. The surgical tactic concludes with closure, any form of immobilization, and the subsequent planned rehabilitation regimen.

Operation Logistics

Operation logistics can be covered as part of the surgical tactic but because of the importance of communicating them with the operative team, it is useful to separate them from the details that are more integral to the surgical procedure. The planned OR table, patient position, and any specific anesthetic needs should be communicated in advance to the OR team. The need for intraoperative fluoroscopy or other radiographic imaging should be communicated. As the surgical tactic is developed, a list of necessary instruments and implants should be generated as well. In addition, it is often useful to add those instruments or implants that do not need to be open and on the sterile field but should be available in case they are needed.

Many surgeons have found it useful to develop an equipment checklist that they provide in advance to the OR personnel. See Figure 7.1. Preference cards do not work well in orthopedic trauma due to the wide variation between cases, making an equipment checklist an effective method to communicate planned equipment needs to the OR personnel.