risk. staging for surgery the pre-operative holding area is so important in the surgical phase since here is where most of the family members can see who the staff of the surgery will be, also this area is where the nurses in charge to give information to the family members of the patient. in the pre-operative holding area, the person preparing for surgery changes out of his or her street clothes and is asked to confirm the details of his or her surgery. a set of vital signs are recorded, a peripheral iv line is placed, and pre-operative medications (antibiotics, sedatives, etc.) are given. when the person enters the operating room, the skin surface to be operated on, called the operating field, is cleaned and prepared by applying an antiseptic (ideally chlorhexidine gluconate in alcohol, as this is twice as effective as povidone-iodine at reducing the risk of infection). if hair is present at the surgical site, it is clipped off prior to prep application. the person is assisted by an anesthesiologist or resident to make a specific surgical position, then sterile drapes are used to cover the surgical site or at least a wide area surrounding the operating field; the drapes are clipped to a pair of poles near the head of the bed to form an "ether screen", which separates the anesthetist/anesthesiologist's working area (unsterile) from the surgical site (sterile). anesthesia is administered to prevent pain from an incision, tissue manipulation and suturing. depending on the kind of operation, anesthesia may be provided locally or as general anesthesia. spinal anesthesia may be used when the surgical site is too large or deep for a local block, but general anesthesia may not be desirable. with local and spinal anesthesia, the surgical site is anesthetized, but the person can remain conscious or minimally sedated. in contrast, general anesthesia renders the person unconscious and paralyzed during surgery. the person is intubated and is placed on a mechanical ventilator, and anesthesia is produced by a combination of injected and inhaled agents. choice of surgical method and anesthetic technique aims to reduce the risk of complications, shorten the time needed for recovery and minimise the surgical stress response. intraoperative phase the intraoperative phase begins when the surgery subject is received in the surgical area (such as the operating theater or surgical department), and lasts until the subject is transferred to a recovery area (such as a post-anesthesia care unit). an incision is made to access the surgical site. blood vessels may be clamped or cauterized to prevent bleeding, and retractors may be used to expose the site or keep the incision open. the approach to the surgical site may involve several layers of incision and dissection, as in abdominal surgery, where the incision must traverse skin, subcutaneous tissue, three layers of muscle and then the peritoneum. in certain cases, bone may be cut to further access the interior of the body; for example, cutting the skull for brain surgery or cutting the sternum for thoracic (chest) surgery to open up the rib cage. whilst in surgery aseptic technique is used to prevent infection or further spreading of the disease. the surgeons' and assistants' hands, wrists and forearms are washed thoroughly for at least 4 minutes to prevent germs getting into the operative field, then sterile gloves are placed onto their hands. an antiseptic solution is applied to the area of the person's body that will be operated on. sterile drapes are placed around the operative site. surgical masks are worn by the surgical team to avoid germs on droplets of liquid from their mouths and noses from contaminating the operative site. work to correct the problem in body then proceeds. this work may involve: excision – cutting out an organ, tumor, or other tissue. resection – partial removal of an organ or other bodily structure. reconnection of organs, tissues, etc., particularly if severed. resection of organs such as intestines involves reconnection. internal suturing or stapling may be used. surgical connection between blood vessels or other tubular or hollow structures such as loops of intestine is called anastomosis. reduction – the movement or realignment of a body part to its normal position. e.g. reduction of a broken nose involves the physical manipulation of the bone or cartilage from their displaced state back to their original position to restore normal airflow and aesthetics. ligation – tying off blood vessels, ducts, or "tubes". grafts – may be severed pieces of tissue cut from the same (or different) body or flaps of tissue still partly connected to the body but resewn for rearranging or restructuring of the area of the body in question. although grafting is often used in cosmetic surgery, it is also used in other surgery. grafts may be taken from one area of the person's body and inserted to another area of the body. an example is bypass surgery, where clogged blood vessels are bypassed with a graft from another part of the body. alternatively, grafts may be from other persons, cadavers, or animals. insertion of prosthetic parts when needed. pins or screws to set and hold bones may be used. sections of bone may be replaced with prosthetic rods or other parts. sometimes a plate is inserted to replace a damaged area of skull. artificial hip replacement has become more common. heart pacemakers or valves may be inserted. many other types of prostheses are used. creation of a stoma, a permanent or semi-permanent opening in the body in transplant surgery, the donor organ (taken out of the donor's body) is inserted into the recipient's body and reconnected to the recipient in all necessary ways (blood vessels, ducts, etc.). arthrodesis – surgical connection of adjacent bones so the bones can grow together into one. spinal fusion is an example of adjacent vertebrae connected allowing them to grow together into one piece. modifying the digestive tract in bariatric surgery for weight loss. repair of a fistula, hernia, or prolapse. repair according to the icd-10-pcs, in the medical and surgical section 0, root operation q, means restoring, to the extent possible, a body part to its normal anatomic structure and function. this definition, repair, is used only when the method used to accomplish the repair is not one of the other root operations. examples would be colostomy takedown, herniorrhaphy of a hernia, and the surgical suture of a laceration. other procedures, including: clearing clogged ducts, blood or other vessels removal of calculi (stones) draining of accumulated fluids debridement – removal of dead, damaged, or diseased tissue blood or blood expanders may be administered to compensate for blood lost during surgery. once the procedure is complete, sutures or staples are used to close the incision. once the incision is closed, the anesthetic agents are stopped or reversed, and the person is taken off ventilation and extubated (if general anesthesia was administered). postoperative care after completion of surgery, the person is transferred to the post anesthesia care unit and closely monitored. when the person is judged to have recovered from the anesthesia, he/she is either transferred to a surgical ward elsewhere in the hospital or discharged home. during the post-operative period, the person's general function is assessed, the outcome of the procedure is assessed, and the surgical site is checked for signs of infection. there are several risk factors associated with postoperative complications, such as immune deficiency and obesity. obesity has long been considered a risk factor for adverse post-surgical outcomes. it has been linked to many disorders such as obesity hypoventilation syndrome, atelectasis and pulmonary embolism, adverse cardiovascular effects, and wound healing complications. if removable skin closures are used, they are removed after 7 to 10 days post-operatively, or after healing of the incision is well under way. it is not uncommon for surgical drains to be required to remove blood or fluid from the surgical wound during recovery. mostly these drains stay in until the volume tapers off, then they are removed. these drains can become clogged, leading to abscess. postoperative therapy may include adjuvant treatment such as chemotherapy, radiation therapy, or administration of medication such as anti-rejection medication for transplants. for postoperative nausea and vomiting (ponv), solutions like saline, water, controlled breathing placebo and aromatherapy can be used in addition to medication. other follow-up studies or rehabilitation may be prescribed during and after the recovery period. a recent post-operative care philosophy has been early ambulation. ambulation is getting the patient moving around. this can be as simple as sitting up or even walking around. the goal is to get the patient moving as early as possible. it has been found to shorten the patient's length of stay. length of stay is the amount of time a patient spends in the hospital after surgery before they are discharged. in a recent study done with lumbar decompressions, the patient's length of stay was decreased by 1–3 days. the use of topical antibiotics on surgical wounds to reduce infection rates has been questioned. antibiotic ointments are likely to irritate the skin, slow healing, and could increase risk of developing contact dermatitis and antibiotic resistance. it has also been suggested that topical antibiotics should only be used when a person shows signs of infection and not as a preventative. a systematic review published by cochrane (organisation) in 2016, though, concluded that topical antibiotics applied over certain types of surgical wounds reduce the risk of surgical site infections, when compared to no treatment or use of antiseptics. the review also did not find conclusive evidence to suggest that topical antibiotics increased the risk of local skin reactions or antibiotic resistance. through a retrospective analysis of national administrative data, the association between mortality and day of elective surgical procedure suggests a higher risk in procedures carried out later in the working week and on weekends. the odds of death were 44% and 82% higher respectively when comparing procedures on a friday to a weekend procedure. this "weekday effect" has been postulated to be from several factors including poorer availability of services on a weekend, and also, decrease number and level of experience over a weekend. postoperative pain affects an estimated 80% of people who underwent surgery. while pain is expected after surgery, there is growing evidence that pain may be inadequately treated in many people in the acute period immediately after surgery. it has been reported that incidence of inadequately controlled pain after surgery ranged from 25.1% to 78.4% across all surgical disciplines. there is insufficient evidence to determine if giving opioid pain medication pre-emptively (before surgery) reduces postoperative pain the amount of medication needed after surgery. postoperative recovery has been defined as an energy‐requiring process to decrease physical symptoms, reach a level of emotional well‐being, regain functions, and re‐establish activities. moreover, it has been identified that patients who have undergone surgery are often not fully recovered on discharge. epidemiology united states in 2011, of the 38.6 million hospital stays in u.s. hospitals, 29% included at least one operating room procedure. these stays accounted for 48% of the total $387 billion in hospital costs. the overall number of procedures remained stable from 2001 to 2011. in 2011, over 15 million operating room procedures were performed in u.s. hospitals. data from 2003 to 2011 showed that u.s. hospital costs were highest for the surgical service line; the surgical service line costs were $17,600 in 2003 and projected to be $22,500 in 2013. for hospital stays in 2012 in the united states, private insurance had the highest percentage of surgical expenditure. in 2012, mean hospital costs in the united states were highest for surgical stays. special populations elderly people older adults have widely varying physical health. frail elderly people are at significant risk of post-surgical complications and the need for extended care. assessment of older people before elective surgery can accurately predict the person's recovery trajectories. one frailty scale uses five items: unintentional weight loss, muscle weakness, exhaustion, low physical activity, and slowed walking speed. a healthy person scores 0; a very frail person scores 5. compared to non-frail elderly people, people with intermediate frailty scores (2 or 3) are twice as likely to have post-surgical complications, spend 50% more time in the hospital, and are three times as likely to be discharged to a skilled nursing facility instead of to