Last reviewed: October 27, 2026.
Preoperative workup is one of those jobs that looks administrative until you have to own it. A patient can have a diagnosis, a booked operation, a consent form and a theatre slot and still not be ready for surgery. The resident’s real task is to turn scattered information into a plan that answers a more useful question: what matters before this patient reaches the operating room?
This is not a universal clearance checklist. Local protocols, the planned operation, anaesthetic practice and patient-specific disease all matter. It is a framework for thinking like the surgical resident who has to present the patient, notice the unresolved problem and know when the plan needs to change.
Start with the operation, not the laboratory panel
A useful preoperative assessment begins by defining what is actually planned. Is the operation elective, time-sensitive or urgent? Is it minor ambulatory surgery or a major abdominal procedure with substantial physiologic stress, bleeding risk and a realistic possibility of postoperative intensive care? Is the operation itself settled, or could the extent change depending on imaging, pathology or intraoperative findings?
That context changes almost everything that follows. A test is useful when its result can alter management. The same haemoglobin, creatinine or cardiac history can have very different implications before a superficial procedure and before a major resection.
Before ordering anything, a resident should be able to state the indication, proposed procedure, urgency, major expected physiologic stresses and the main unresolved question. This is the preoperative equivalent of the problem representation used elsewhere in clinical medicine.
The history should look for things that can change the plan
The goal is not to reproduce the entire medical record. Focus on conditions that affect anaesthesia, operative risk, bleeding, wound healing, postoperative disposition or whether surgery should proceed at all.
That usually means clarifying cardiovascular symptoms and functional capacity; pulmonary disease and recent respiratory problems; diabetes; kidney and liver disease; previous thromboembolism; bleeding history; immunosuppression; relevant infection; previous anaesthetic problems; allergies; nutrition and recent unintentional weight loss; smoking; frailty when relevant; and previous operations that could alter the planned approach. For major abdominal surgery, prior operative reports and cross-sectional imaging can matter as much as another blood test.
Medication reconciliation deserves its own pass. Anticoagulants and antiplatelet drugs, insulin and other glucose-lowering medication, steroids, immunosuppressants and cardiovascular drugs may require a specific perioperative plan. Do not convert a complex medication decision into a memorised stop-date without checking the indication, renal function, thrombotic risk, bleeding risk and local guidance.
One current example is SGLT2 inhibitors. The 2026-reaffirmed AHA/ACC multisociety perioperative guideline recommends withholding them before planned surgery because of perioperative metabolic-acidosis risk; the guideline specifies three to four days. That is exactly the kind of medication detail that can be missed when the pre-op review is treated as paperwork.
Examination: targeted does not mean superficial
A resident does not need to perform every examination manoeuvre ever learned. The examination should answer questions raised by the history and operation. Assess general condition and vital signs. Look for evidence of decompensated cardiac or respiratory disease when relevant. Examine the abdomen for scars, hernias, masses or stomas if they affect access or operative planning. In patients undergoing cancer surgery or major abdominal procedures, functional status and evidence of frailty or malnutrition may be more informative than an elaborate normal systems examination.
Do not confuse “pre-op” with “order everything”
Routine testing is not automatically safer. NICE guidance on elective preoperative testing explicitly discourages several blanket practices: routine chest radiographs are not recommended, resting echocardiography should not be ordered routinely, urine dipsticks should not be routine, and HbA1c is not recommended simply because a person without known diabetes is having surgery. The appropriate laboratory and diagnostic workup depends on the operation, comorbidities and what a result would change.
Think test by test. A full blood count may matter because of anaemia, infection, thrombocytopenia or expected blood loss. Renal function and electrolytes matter when kidney disease, fluid shifts or medication management are relevant. Coagulation studies are not a universal proxy for bleeding risk. Group-and-screen or crossmatch planning depends on the procedure and institutional blood-bank practice. Additional liver, endocrine or disease-specific testing should have a clinical reason.
Cardiac risk: the question is whether more information will change management
The current AHA/ACC approach to cardiovascular assessment is deliberately stepwise. The 2024 multisociety guideline was formally reaffirmed in September 2026 as current. It recommends combining the procedure, urgency, clinical status and validated risk tools when appropriate rather than sending patients reflexively for cardiac testing.
For residents, the practical lesson is important: stress testing is not routine preoperative clearance. The guideline reserves it for selected patients with poor or unknown functional capacity and elevated perioperative risk when the result is likely to influence management. Low-risk patients, people with good functional capacity and those undergoing low-risk procedures should not undergo routine stress testing solely because an operation is planned.
If the patient has unstable or complex cardiovascular disease, the correct resident move is not to manufacture certainty. Identify the issue, determine whether the operation can wait and involve anaesthesia, cardiology and the responsible surgeon as appropriate. Good preoperative work is partly knowing when the decision has become multidisciplinary.
Optimization is part of the workup
Finding a risk factor without deciding what to do about it is only half an assessment. The ACS Strong for Surgery program focuses preoperative screening and intervention on modifiable factors including nutrition, smoking and glycaemic issues. In practice, optimization may include treating significant anaemia, improving nutrition, planning smoking cessation, controlling diabetes, managing infection, reviewing anticoagulation, arranging prehabilitation or changing postoperative monitoring plans.
The key is proportionality. Optimization should reduce meaningful risk without creating endless delays in patients whose disease is itself time-sensitive. Cancer surgery makes this tension obvious: “make everything perfect first” is not always a safe strategy.
The resident’s pre-op synthesis
By the end of the review, you should be able to present more than a list of diagnoses. A useful synthesis sounds like this in structure: the patient is undergoing this operation for this indication; the major perioperative issues are these two or three things; this has already been addressed; this remains unresolved; and this is what needs to happen before theatre.
That last sentence is where junior preoperative work often improves most. “Cardiology reviewed” is not a plan. “Apixaban stopped” is incomplete without knowing why the patient takes it and when it should resume. “CT done” is not enough if nobody has reviewed the anatomy that changes the operation. “Bloods acceptable” is not a meaningful summary if the haemoglobin has fallen substantially from baseline.
A practical resident sequence
When time is limited, work in the same order every time. First, define the indication, operation and urgency. Second, identify patient factors that can alter anaesthesia, bleeding, operative approach or recovery. Third, reconcile medications with perioperative consequences. Fourth, review relevant examination findings, laboratory trends, imaging, pathology and prior operative information. Fifth, estimate procedure-specific and patient-specific risk rather than ordering tests reflexively. Sixth, identify what needs optimization or specialist input. Finally, state the unresolved issues and who owns each one.
This sequence is more useful than memorising a universal panel because it scales. The details change between an elective hernia repair and a pancreatic resection, but the reasoning architecture remains recognizable.
What belongs to the resident — and what does not
Residents are expected to become increasingly capable of identifying risk, gathering the right information and proposing a plan. That does not mean independently resolving every perioperative problem. Complex anticoagulation, unstable cardiovascular disease, difficult airway history, severe organ dysfunction and major disagreement about whether an operation should proceed may require senior surgical, anaesthetic or specialty input.
The useful skill is escalation with synthesis. Instead of “Can you review this patient?”, bring the operation, urgency, relevant disease, current findings and the decision you need help making. That same principle appears in our guides to calling your senior and preparing for an operation.
The morning-of-surgery check is not the original workup repeated
On the day of surgery, the job is to identify what has changed and confirm that critical prerequisites are complete. Has the patient’s condition changed overnight? Are relevant medications managed as planned? Is consent complete and still valid for the intended procedure? Is the operative site or side clear when applicable? Are important laboratory abnormalities addressed? Is blood availability arranged when needed? Has new imaging or pathology changed the plan? Does anaesthesia know about the issues that matter?
If consent is part of your role, our guide to informed consent as a surgical resident covers that conversation in detail. The point here is that preoperative workup and consent are related but not interchangeable: one establishes readiness and risk; the other supports an informed patient decision.
What this skill becomes later in residency
Early in training, pre-op work often feels like collecting requirements. Later, the emphasis shifts toward anticipation. You begin asking what will make this operation difficult, what could make it unsafe, what the postoperative bottleneck is likely to be and which apparently small detail will matter six hours from now.
That is why preoperative workup belongs inside surgical training rather than outside it. It is one of the places where residents learn to connect diagnosis, physiology, imaging, medications, operative strategy, anaesthesia and postoperative care into one coherent decision. The goal is not to make the chart look complete. The goal is to make the operation and its surrounding care safer, clearer and more deliberate.
Sources and Further Reading
- American College of Cardiology — 2026 reaffirmation of the multisociety perioperative cardiovascular guideline.
- ACC — Key points from the AHA/ACC multisociety perioperative cardiovascular guideline.
- NICE NG45 — Routine preoperative tests for elective surgery.
- American College of Surgeons — Strong for Surgery.
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