General Surgical Services Operational Policy

MOH/P/PAK/389.
18
GENERAL
SURGICAL
SERVICES
OPERATIONAL
POLICY
MEDICAL DEVELOPMENT DIVISION

Ministry of Health Malaysia
2018
MINISTRY OF HEALTH MALAYSIA
2018
GENERAL SURGICAL SERVICES OPERATIONAL POLICY

Coordinated by:
Surgical and Emergency Medicine Services Unit
Medical Services Development Section
Medical Development Division
© The Ministry of Health Malaysia 2018
www.moh.gov.my
MOH/P/PAK/389.18 (BP)
ISBN 978-967-2173-12-0
All copyrights reserved.
No part of this policy may be reproduced or transmitted, in any form or by
any means, electronic or mechanical, including photocopying, recording or by
any information storage or retrieval system, without prior permission from the
Publisher.
Published by:
Surgical and Emergency Medicine Services Unit,
Medical Services Development Section of Medical Development Division of
Ministry of Health Malaysia and
The Drafting Committee of General Surgical Services Operational Policy
A catalogue record of this document is available from the

Library Block E7, Resource Unit Block E1
Institute for Medical Research

National Library of Malaysia
Softcopy of the document is available at www.moh.gov.my

Limitation:
There are many variations in the design, location, facilities, support services and
the presence or absence of subspecialty services in the hospitals managed by
the Ministry of Health Malaysia. There are also variations in human resource
providing the general surgical services located in these hospitals in terms of
numbers, level of experience, training and capability. There are numerous factors
accounting for these variations.
The operational policies are practices which should be within the capability of
most hospitals. The policy outlined in this document is for the surgical services,
Ministry of Health Malaysia. Efforts will be made by all those concerned with
planning, operational activities and evaluation of such services to ensure that the
majority of hospitals would be able to adhere to these policies and standards.
Hospitals will continue to be accountable for all the services that they provide in
good faith for the benefit of the patients that they serve.
ACHIEVING EXCELLENCE
IN GENERAL
SURGICAL SERVICES
Framework document and companion guide for
provision of safe, quality and patient-centered services
TABLE OF CONTENTS
Foreword
Director General of Health Malaysia i
Preface
Chairman of General Surgical Services Operational Policy ii
National Head of General Surgical Services iii
Section I. Editorial board and contributors

Editors 1
Contributors 4
Section II. The policy

CHAPTER 1 :
Introduction 9
CHAPTER 2 :
Aim of the policy 10
CHAPTER 3 :
Vision, mission and objectives 11
CHAPTER 4 :
Hospital category 12
CHAPTER 5 :
Scope of services 13
5.1 Outpatient clinic services 13
5.2 Inpatient services 14
5.3 Surgery: 14
5.3.1 Elective Surgery
5.3.2 Emergency surgery
5.3.3 Clinical issue
5.4 Endoscopy 18
5.5 Networking and cluster 18
CHAPTER 6 : Clinical operational policy 19
6.1 Operation theatre 19
6.2 On call policy: 19
6.2.1 Consultant
6.2.2 Specialist
6.2.3 Medical officer (with qualification of specialist)
under gazettement
6.2.4 Medical officer
6.3 Credentialing and privileging 21
6.4 Informed consent 21
6.5 Referral system 21
CHAPTER 7 : Training and education 22
CHAPTER 8 : Quality Assurance 23
General Surgical Services Operational Policy 2018 7

TABLE OF CONTENTS
Section III. Subspecialty and specialty services

1. Subspecialty of general surgical services 27
1.1 Breast and endocrine surgery 27

1.2 Vascular surgery 28
1.3 Colorectal surgery 29
1.4 Hepatopancreatobiliary surgery 29
1.5 Upper gastrointestinal surgery 30
1.6 Thoracic surgery 30
1.7 Trauma and burns 30
2. Specialty services 31
2.1 Paediatric surgery 31

2.2 Neurosurgery 34
2.3 Urology 34
Section IV. Appendices

Appendix 1 : Organization chart of General Surgical Services 37
(state level)
Appendix 2 : Terms of Reference of General Surgeon 38
Appendix 3 : Terms of Reference of Head of The Department 40
Appendix 4 : Terms of Reference of State Head of General 42
Surgical Services
Appendix 5 : Terms of Reference of MOH Head of General 43
Surgical Services
Appendix 6 : Term of Reference of MOH Head of Subspecialty 44
Appendix 7 : Template for OT list 45
Appendix 8 : Negotiated list and OT utilisation 46
Appendix 9 : Recommendation for management of patient with 47
peripheral vascular complication requiring
amputation
Appendix 10 : Consent for operation/procedure 48
Appendix 11 : Photography/multimedia consent form 50
Appendix 12 : Testimonial letter of Refusal or 51
Treatment/Procedure
Appendix 13 : Key Performance Indicator (KPI) 52
Appendix 14 : List of practice points, pitfalls & audit point 60
8 General Surgical Services Operational Policy 2018

TABLE OF CONTENTS
Section V. List of procedures

Table 1 : Breast and Endocrine Surgery 67
Table 2 : Vascular surgery 68
Table 3 : Colorectal surgery 69
Table 4 : Hepatopancreatobiliary surgery 70
Table 5 : Upper gastrointestinal surgery 71
Table 6 : Thoracic surgery 72
Table 7 : Trauma and burns 72
Table 8 : Paediatric surgery 73
Table 9 : Neurosurgery 74
Table 10 : Urology 74
Table 11 : List of procedures (medical officers) 75
References 77
List of abbreviations 79

FOREWORD
DIRECTOR GENERAL OF HEALTH MALAYSIA
Malaysia is proud of the strong foundations laid since independence in

providing surgical services.
We have now entered the consolidation phase of quality improvement

activities and our emphasis is on patient safety rather than just an outcome
based approached in our thrust towards patient centered care and
services.
Operational policies are imperative therefore in ensuring a uniform delivery

of quality services.
I am pleased that this operational policy conforms to the highest

international and national standards of hospital accreditation bodies. We
must always strive for excellence and I congratulate the team that has
developed this operational policy, for leading the way in conforming to
international standards.
I hope this Operational Policy of General Surgical Services of Malaysia will

form another milestone in the advancement of subspecialties in Malaysia
YBhg Datuk Dr Noor Hisham bin Abdullah

Director General of Health, Malaysia
i General Surgical Services Operational Policy 2018

PREFACE
CHAIRMAN OF GENERAL SURGICAL SERVICES
OPERATIONAL POLICY
The preparation of the General Surgical Services Operational Policy was

started after the Annual Heads of Surgery meeting in 2016. It is to serve as
a guide to Heads of General Surgical Departments in the Ministry of Health
in their day to day administration and conduct of professional duties.
It contains general outlines of scope of services provided, our direction and

requirement for good governance. Categorisation of hospitals according to
Surgical bed strength has been made to facilitate comparison of staff
strengths and workload for planning purposes.
This document has highlighted Practice Points and Pitfalls to address

areas that need special attention.Current solutions to some outstanding
and contentious problems with other related disciplines has been included.
Examples of this are the `Negotiated List’ and the ‘Management of patient
with peripheral vascular complication requiring amputation’. Some relevant
policies which are common to all disciplines have also been included with
their corresponding references.
This document is the first for the General Surgical fraternity. It would not
have been possible without the input from all those involved including the
Specialty and Subspecialty Heads of Service. A special word of thanks to
Dr. Patimah Amin and her team for their tireless effort in making this
document a reality.
As with all policy documents, it shall be reviewed.
YBhg Dato’ Dr Abdul Jamil bin Abdullah

Senior Consultant General Surgeon
General Surgical Services Operational Policy 2018 ii

Message from
the National Head of General Surgical Service
Over the years, Surgical Services in the Ministry of Health Malaysia has
expanded in terms of facilities and scope of services provided.
General Surgical Services are provided by the general surgeons and the
sub specialists.
The healthcare facilities also vary from one extreme of non-specialist

hospital to tertiary hospitals with subspecialist. With the diversity of
workforce providing the similar scope of services, variations in terms of
process of care are inevitable with resultant disparity in quality of care
between facilities. The Lancet Commission on Global Surgery in their report
Global Surgery 2030, has five key messages which highlights indicators that
should be measured to assess quality of surgical care.
During the Ministry of Health Malaysia Surgeons Annual Meet in 2017, the
need for a surgical policy was endorsed, with the intention of streamlining
surgical services. This policy document draws the guidelines for general
surgical services which include subspecialties under general surgery, which
are Breast and Endocrine, Upper Gastrointestinal, Hepatopancreatobiliary,
Colorectal, Thoracic, Vascular and Trauma. Basic Paediatric Surgery
procedures and Neuro Trauma Surgery procedures are also covered in this
policy.
It is hoped that with this policy document, the variations in delivery of care
would to a certain degree be narrowed. The heads of all surgical
departments are expected to review their current practises and ensure that
this policy is adhere to. This policy will be reviewed in year 2023 and
updated if necessary with the latest developments and progress in surgical
care.
YBhg Dato’ Seri Dr Mohamed Yusof bin Haji Abdul Wahab

National Advisor of General Surgical Services
iii General Surgical Services Operational Policy 2018

SECTION I
Editorial board & Contributors
“Wherever the art of medicine is loved,

there is also a love of humanity.”
Hippocrates
General Surgical Services Operational Policy 2018 iv

v General Surgical Services Operational Policy 2018
EDITORIAL BOARD
CHIEF ADVISOR
Dato’ Dr Haji Azman bin Haji Abu Bakar

Deputy Director General of Health (Medical)
ADVISORS
Dato’ Dr Haji Bahari bin Dato’ Tok Muda Haji Che Awang Ngah
Director
Dr Ahmad Razid bin Salleh

Director
Medical Practise Division
Datin Sri Dr Asmah binti Samat

Senior Principal Assistant Director
Medical Development Services Section
Dr Mohd Fikri bin Ujang

Senior Deputy Director
Medical Professional Development Section
Dr Paa Mohamed Nazir bin Abdul Rahman

Senior Deputy Director
Medical Care Quality Sector
Dr Patimah binti Amin

Dr Laili Murni binti Mokthar

Senior Assistant Director
Hospital Management Services Unit

EDITORIAL BOARD
CHAIRMAN
Dato’ Dr Abdul Jamil bin Abdullah

Hospital Sultanah Nur Zahirah,Terengganu
MEMBERS OF DRAFTING COMMITTEE
Dato’ Seri Dr Mohamed Yusof bin Haji Abdul Wahab

Hospital Tengku Ampuan Rahimah, Klang
Dato’ Dr Jiffre bin Din

Hospital Tengku Ampuan Afzan, Kuantan
Dato’ Dr Wan Khamizar bin Wan Khazim

Senior Consultant General and Colorectal Surgeon
Hospital Sultanah Bahiyah, Alor Setar
Dato’ Dr Nik Mohamad Shukri Nik Yahya

Hospital Raja Perempuan Zainab II, Kota Bharu
Datuk Dr Muhammad Safian bin Naim

Hospital Melaka
Dato’ Dr Fitjerald Henry

Hospital Selayang
Dr Nor Aina binti Emran

Senior Consultant General and Breast and Endocrine Surgeon
Hospital Kuala Lumpur
Dr Yan Yang Wai

Hospital Raja Permaisuri Bainun, Ipoh

EDITORIAL BOARD
Dr Jasiah binti Zakaria

Hospital Tuanku Ja’afar, Seremban
Dr Narasimman Sathiamurthy
Senior Consultant General and Thoracic Surgeon
Dr Lewellyn Rajakumar Kovil George

Hospital Teluk Intan
Dr Lee Yuk Loong

Hospital Shah Alam
Dr Kenneth Voon Kher Ti

General Surgeon
Hospital Raja Perempuan Zainab II, Kota Bharu
Dr Nagarajan T Vellasamy
Hospital Seberang Jaya

CONTRIBUTORS
Datuk Dr Zainal Ariffin bin Azizi

Senior Consultant Vascular Surgeon
Dato’ Dr Jahizah binti Hassan

Senior Consultant Cardiothoracic Anesthesiology and Perfusionist
Dato’ Dr Zakaria bin Zahari

Senior Consultant Paediatric Surgeon
Dato’ Dr Johari Siregar bin Adenan

Senior Consultant Neurosurgeon
Dr Lim Shyang Yee

Senior Consultant General and Upper Gastrointestinal Surgeon
Hospital Pulau Pinang
Dr Manisekar Subramanian
Senior Consultant General and Hepatopancreatobiliary Surgeon
Hospital Sultanah Bahiyah, Alor Setar
Dr Rizal Imran bin Alwi

Senior Consultant Trauma and Burn
Hospital Sultanah Aminah, Johor Bharu
Dr Praveen Nadarajah
Senior Medical Officer
Department of General Surgery
Dr Thee Li Jie
Senior Medical Officer
Department of General Surgery

Dr Faizah binti Muhamad Zin
Head of Clinical Audit Unit
Medical Care Quality Section
POMR Drafting Committee Members


SECRETARIATS
Dr Zahirah binti Juraimi

Dr Abdul Hakim bin Abdul Rashid

Dr Umawathy Sundrarajoo
Dr Mohd Fadzil bin Mohd Irwan

Puan Sabariah binti Ahmad

Chief Nurse
Puan Noor Azmah binti Ahmad Zaki

Administrative Assistant

SECTION II
The Policy
“If the love of surgery is a proof of a person’s being

adapted to it, then certainly i am fitted to be a
surgeon, for thou canst hardly conceive what a
high degree of enjoyment i am from day to day
experiencing in this bloody and butchering
department of the healing art. I am more and
more delighted with my profession.”
Lord Joseph Lister 1827-1912, English Surgeon

Chapter 1: Introduction
1.1 Malaysia became a signatory in 2006 to international efforts led by

the World Alliance for Patient Safety. The Ministry of Health Malaysia
(MOH), as the lead agency for health in the country, is committed to
driving the health care sector in the provision of safe, effective &
efficient surgical services via good clinical governance.
1.2 The design of this policy document is based on a people-centred

health care service and gives priority to performance, as embodied in
the tagline: “People First, Performance Now”.
1.3 The Lancet Commission on Global Surgery 2030 demonstrated 5

key messages focused on surgery:
 Access to safe, affordable surgical and anaesthesia care when

needed.
 Additional surgical procedures are needed each year to save
lives and prevent disability.
 Protection against catastrophic out-of-pocket expenditure due
to payment for surgery and anaesthesia.
 Investment in surgical and anaesthesia services is affordable,
saves lives, and promotes economic growth.
 Surgery is an indivisible, indispensable part of health care
system.
1.4 As the biggest health care provider, hospitals in the MOH play an
important leading role in the development and provision of general
surgical services in Malaysia. These services are provided by general
surgical units in state, major specialist, minor specialist and non-
specialist hospitals.

Chapter 2: Aim of the policy
2.1 This document is intended to describe the policy direction of general

surgical services provided in MOH hospitals.
2.2 This policy will serve primarily to guide the HOD & other stakeholders
on the requirements, business process and standard of care in
development of general surgical services.
2.3 This policy document covers key areas of general surgical services
such as organisation, human resource, standards and clinical
governance.
2.4 This document shall be reviewed in 2023 or earlier if the need arises.

Chapter 3: Vision, mission and objectives
3.1 Vision of the general surgical services is to provide safe and

sustainable care.
3.2 Mission is to provide safe services that are patient-centred,

efficient and committed to training.
3.3 Objectives:
3.3.1 SERVICE:
• To embrace the WHO “Safe Surgery Saves Lives”

initiative.
• To develop services in tandem with the cluster concept.
• To improve cancer care via “Patient Navigation

Program”.
3.3.2 TRAINING:
• To support advancement of surgical training via

subspecialisation and General Surgeon with Interest
(GSWI).
• To facilitate career development of Medical Officers in

surgery.

Chapter 4: Hospital category
4.1 MOH hospitals are categorised as state, major specialist, minor

specialist, non-specialist hospitals & special medical institutions. The
list of current hospitals under MOH refers to the existing Speciality
and Subspecialty Framework of Ministry of Health Hospitals under
11th Malaysia Plan. [1]
4.2 Scope of services provided is based on the category of the hospitals

and the resources available.
4.3 Designated major specialist and state hospitals shall provide tertiary
level subspecialty services and training. [1]
4.4 Specialist services for non-specialist hospitals shall be provided

through the cluster and networking arrangement from lead hospitals
or other hospitals. The arrangement shall include:
4.4.1 Designation of beds in smaller hospitals within the cluster

network where the members of the surgical department from
lead hospital can provide surgical services required.
4.4.2 Coordination of hospital to transfer acutely ill patients through

provision of adequate number of functioning ambulances
and trained human resources to accommodate the expected
increase of patient movement for inter-hospital transfer for
step-up/step-down care.
4.5 The Organisation chart of a general surgical service is as per

Appendix 1.
4.6 Term of reference for the various heads of surgery is as per

appendices:
Appendix 2: TOR of General Surgeon.

Appendix 3: TOR of Head of the Department
Appendix 4: TOR of State Head of General Surgical Services
Appendix 5: TOR of MOH Head of General Surgical Services
Appendix 6: TOR of MOH Head of Subspecialty
Chapter 5: Scope of services

Chapter 5: Scope of services
5.1 OUTPATIENT CLINIC SERVICES
Clinic appointment:
i All new cases shall be seen by appointment.
PRACTICE POINT 1
ii. Date of appointment shall be determined by an MO after

reviewing the referral letter.
iii. Based on the urgency of the case, patient may be seen on the
same day.
PITFALL
 Triaging done by paramedics may result in
delay of appointment for urgent cases.
PRACTICE POINT 2
iv. Patients suspected of having malignancy should be given an

early appointment (within 2 weeks). The management of these
cases should be specialist-led.
PRACTICE POINT 3
v. There should be a system in place to trace patients with

malignancy who defaults.
vi. Patients deemed not requiring specialist care can be discharged

to a Primary Care Clinic/non-specialist hospital.

5.2 INPATIENT SERVICES
PRACTICE POINT 4
i. The overall care of patients in the surgical wards shall be under
the responsibility of a consultant or specialist.
PRACTICE POINT 5
ii. A specialist should review and be involved in the management

of all critically ill patients.
iii. Specialist should engage with family members of critically ill

patients to update on the progress and care plan of the patients.
PRACTICE POINT 6
iv. Appointment for follow up should be given upon discharge,

and in the event where this is not feasible, the staff should call
the patient and inform the appointment date.
PITFALL
 Patients who were discharged over the
weekend were made to call back for a follow
up appointment.
5.3 SURGERY
5.3.1 ELECTIVE SURGERY:
(A) ELECTIVE: INPATIENT
i. An operation list for elective surgery shall be made available at

least one day prior to surgery.
ii. The minimum data set in an operation list should include details
as per template in Appendix 7.
iii. The name of the operating surgeon must be stated for each
procedure.

PRACTICE POINT 7
iv. The name of the consultant/surgeon in charge of the theatre

must be specified in the list. He shall determine the sequence
of the cases and their respective theatres.
v. All elective cases must be reviewed pre-and post-operatively

by the operating surgeon.
vi. All cases posted for elective surgery shall be optimised and
referred to anaesthesiology clinic prior to listing.
vii. Postponed cases should be given priority preferably on the

next available list.
viii. Scheduling of elective cases should be based on the Guideline

of Prioritisation of Cases for Emergency and Elective Surgery
in Ministry of Health Malaysia 2018. [2]
ix. All surgical departments should ensure that MIS techniques

are encouraged to be used for established MIS surgical
procedures. Patients are encouraged to opt for MIS techniques
and are appropriately advised the benefits of MIS.
x. Negotiated List: Is an elective list that has been agreed upon by

anaesthesiologists and the surgeons within a stipulated time. It
is meant to reduce cancellation of cases. Refer to excerpts of
minutes of the meeting as per Appendix 8. [5]
(B) DAY CARE SURGERY
i. Hospitals with specialists shall consider Day Care Surgery as

of high priority for simple uncomplicated cases.
ii. To ensure good utilization of Day Care Surgery, hospitals with

specialists shall identify index surgeries to be done as
Day Care.
iii. Utilisation of this service shall be monitored as per existing

guidelines.[3]& [4]

5.3.2 EMERGENCY SURGERY
The prioritisation of surgery for emergency cases is as follows:
(A) Acute Emergency
i. Patient’s condition, which requires immediate operation,i.e.

life threatening situation, failing which life/limb will be lost.
Surgery may proceed without baseline investigation/patient
being fasted.
(B) Emergency
i. Patient’s condition, who are haemodynamically stable that

require operative procedure to be carried out, otherwise life is
threatened or morbidity increased.
• Trauma (<6 Hours): Non-life threatening condition but if

the operation is carried out after 6 hours, it will increase
patient morbidity and mortality risk.
• Non-trauma (<8 Hours): Non-life-threatening condition but

if the operation is carried out after 8 hours, it will increase
patient morbidity and mortality risk.
PRACTICE POINT 8
ii. In the event of overwhelming number of emergency cases,

elective surgeries may be postponed accommodating them
(responsibility of the HOD).
PITFALL
 Information about long emergency list not

brought to the attention of the surgical/
anaesthesiology HOD to reprioritise the
utilisation of operation theatre.
 Absence of a contingency plan to clear long

emergency list especially after hours and
during public holidays.

(C) Urgent
i. Patient’s condition, which requires operative procedure within

24-hours otherwise there is increase in morbidity.
(D) Semi-urgent
i. Patient’s condition which requires operative procedure within

1/52 otherwise there may be increase in morbidity.
ii. Refer to MOH Guideline of Prioritisation of Cases for Emergency

and Elective Surgery in Ministry of Health Malaysia 2018. [2]
5.3.3 CLINICAL ISSUES (CI)
• Management of patient with peripheral vascular complication

requiring amputation.
• May vary due to local limitation or practice.
Scenario:
In a hospital without vascular surgeon, a patient with peripheral
vascular disease in the surgical ward had amputation done by the
Orthopedic surgeon.
Issue:
Should the patient be managed in a general surgical or orthopedic
ward?
Recommendation:
Postoperative care of the patient is the responsibility of the operating
surgeon. Refer to existing document as per Appendix 9. [6]

5.4 ENDOSCOPY
5.4.1 OGDS, colonoscopy & cystoscopy services shall be provided

in all hospitals with specialists.
5.4.2 ERCP services shall be provided by all major/state & selected

minor specialist hospitals where facilities and expertise are
available.
5.4.3 All OT complexes should have endoscopy sets for use in the
theatre.
5.5 NETWORKING AND CLUSTER
Surgical speciality services shall be provided to all cases that require

attention in non-specialist hospitals through either of the following way:
5.5.1 Through an established network with designated specialist

hospital within similar geographical location. This may or may
not require referral to the specialist hospital, depending on
resources available in the non-specialist hospital and nature of
the case.
5.5.2 Through cluster network where surgical specialists from other

hospitals within the cluster (i.e. major specialist hospital/minor
specialist hospital/state hospital) provides surgical services via
an entire disciplinary team approach. This is ONLY applicable
to existing cluster hospitals where surgical services are being
offered. Note that referrals are NOT required to transfer patient
within a cluster network.
Chapter 6: Clinical operational policy

Chapter 6: Clinical operational policy
6.1 OPERATION THEATRE
i. The attire to be worn in the operating theatre should follow the

local hospital guideline.
ii. Staff who leaves the theatre complex with the OT attire should
change on returning.
PRACTICE POINT 9
iii. All surgeons should follow the “Safe Surgery Saves Lives”
guideline. [7]
PITFALL
 Surgeons are known to skip
the TIME OUT.
6.2 ON CALL POLICY
i. All major specialist hospitals shall provide on call services by

consultant, specialist & MO.
ii. In hospitals without consultants, on call services shall be

provided by the specialist & MO.
iii. Specialist doing passive call must be staying within 33km

radius or 30 minutes journey to hospital. [8]
6.2.1 CONSULTANT:
i. Shall do passive call.
ii. All surgical units with subspecialty services shall do

general surgical consultant call with the exceptions of
Vascular and HPB surgery in designated centres.

6.2.2 SPECIALIST:
i. State and major specialist hospital:
• Hospitals with 5 to 7 or more specialists should provide

active call.
ii. Minor specialist hospital:
• Specialist shall do passive call and only 1 level

specialist care shall be provided.
• If specialist call services cannot be provided
arrangement to cover should be in place.
6.2.3 MEDICAL OFFICER (WITH SPECIALIST

QUALIFICATION) UNDER GAZETTEMENT
i. The HOD shall be responsible for the training of

medical officer (with specialist qualification) undergoing
gazettement.
ii. The HOD must inform medical officer (with specialist

qualification) undergoing gazettement with regards to his
training and need to have a feedback session at the end
of 3 months of training. In the event where extension
is anticipated, the medical officer (with specialist
qualification) under gazettement should be informed by
the 5th month.
iii. Extension of gazettement period shall be considered for:
(a) Reason: Issues related to competency, knowledge,

case management and attitude.
(b) Duration: Will be a minimum of 3 months and a
maximum of 12 months.
(c) Placement: At the same hospital for 3 – 6 months.
(d) Re-evaluation: If the medical officer (with specialist
qualification) is unable to be gazetted by 12 months,
he/she should be sent to a different hospital for
re-evaluation.
6.2.4 MEDICAL OFFICER:
i. The number of MOs on active calls shall be decided by

the HOD based on the needs of the department.
ii. Refer to DG circular for on call services. [8]

6.3 CREDENTIALING AND PRIVILEGING
6.3.1 Surgical services are to be provided by adequately trained

credentialed doctors and specialists. All categories of staff
shall be credentialed and privileged to perform specific tasks
appropriate to their skills and competency. Refer to existing
guideline. [9]
6.4 INFORMED CONSENT
6.4.1 Informed consent should be obtained for all surgical procedures,

as per Appendix 10 & 11.
6.4.2 All consent must be taken by the MO or specialist using the

appropriate consent form as per Appendix 10, 11 & 12.[14] & [15]
6.4.3 The use of information leaflet is encouraged.
6.4.4 Validity and duration:
• Consent will remain valid until it is withdrawn by the patient

or if there is a material change in the circumstances. Refer
to existing directive. [10]
6.4.5 Eligibility and age:
• In life saving situation, where all efforts to trace the relatives

and next of kin have failed, two clinical specialists, one of
whom is from the related discipline can give consent for the
clinical procedure to be carried out.
• The consent taken, and the efforts made to trace the next of
kin must be documented in the case notes.
• Refer to MMC guidelines and General Hospital Operational

Policy for consent pertaining eligibility and age. [10] & [11]
6.5 REFERRAL SYSTEM
6.5.1 Referrals to a General Surgical Department shall follow the

existing MOH guidelines. [12]

Chapter 7: Training and education
7.1 Training for all the staffs shall be the responsibility of the HOD.
7.2 The HOD shall, in discussion with staff, formulate a career development
plan for them.

Chapter 8: Quality Assurance
8.1 Reporting of perioperative mortalities via e-POMR shall be monitored.
8.2 All surgical departments with specialist services should conduct clinical
audit.
8.3 Comply with “Safe Surgery Saves Lives” initiative. [7]
8.4 KPI indicators shall be reported as per policy. [13]

SECTION III
Subspecialty and specialty services
“It is surgeon’s duty to tranquillize the temper, to

beget cheerfulness, and to impart confidence of
recovery.”
Sir Astley Paston Cooper 1768-1841, English Surgeon

1. Subspecialty of General Surgical Services
i. The recognised subspecialties under General Surgery are Breast

and Endocrine, Vascular, Colorectal, Hepatopancreatobiliary, Upper
Gastrointestinal, Thoracic and Trauma & Burns Surgery.
ii. The development and delivery of each subspecialty of General

Surgical Services shall be coordinated and integrated within the
General Surgical Services.
iii. Each subspecialty of General Surgical Services shall be headed by

its respective Head of Subspecialty at the MOH level.
iv. Scope of services of the subspecialty is as per General Surgical

Services. Refer to Section II: Chapter 5.
v. Subspecialty Fellowship is a 3 years training program that would be

certified by the Board / Committee of the respective subspecialty to
qualify for NSR registration.
vi. Centres providing subspecialty services:
(a) Regional centres: These centres shall provide service,

subspecialty training and research. [1]
(b) Service centres : These are centres providing subspecialty

services as part of the General Surgical Services in that facility.
vii. List of surgical procedures that should be provided by the surgeon

is tabulated as per Section V.
1.1 BREAST AND ENDOCRINE SURGERY (B&E)
1.1.1 The subspecialty field of B&E Surgery generally covers

diseases of the breast and almost all endocrine glands in the
body. These include thyroid, parathyroid glands, pancreas
and adrenal glands.
PRACTICE POINT 10
1.1.2 Breast cancer patients, where feasible should be managed

through MDT.

1.1.3 General Surgeons performing hook-wire localization & wide
local excisions are required to monitor their performance
using KPI for B&E. Refer to Appendix 13. [13]
1.1.4 The scope of B&E Surgery is as per General Surgical Services.

Refer to Section II, Chapter 5.
1.1.5 To improve the management of breast cancer patients,

a dedicated “One stop centre” is encouraged. This will
comprise of dedicated Breast Clinic, with the support of
Radiology & Pathology services during the same clinic hour.
This enables the patient suspected of breast cancer to be seen
by the surgeon and subsequently undergo imaging studies as
well as biopsy on the same day.
1.1.6 Privilege to perform surgery related to B&E is as in Section V,

Table 1.
1.2 VASCULAR SURGERY
1.2.1 The subspecialty field of Vascular Surgery generally covers

disease affecting all parts of the vascular system except the
heart and the brain. This includes the diseases of the aorta
and peripheral arteries, which are the domains of a vascular
surgeon. It also includes varicose veins and vascular access for
haemodialysis, which can also be managed by general surgeon
with adequate training and exposure.
1.2.2 Other vascular conditions such as vascular malformations and

trauma can also be managed by other surgical disciplines with
adequate exposure and training.
1.2.3 The scope of Vascular Surgery is as per General Surgical

Services and include non- invasive vascular laboratory. Refer
to Section II, Chapter 5.
1.2.4 Appointments and referrals: Non-urgent cases are seen in the

outpatient clinic on an appointment basis. Referrals can be sent
in via fax and appointment will be given on the next available
slot. Cases that need urgent vascular attention can be referred
to the on-call team and will be discussed with the vascular
consultant.
1.2.5 Privilege to surgical procedures that should be provided by the

surgeons is as per Section V, Table 2.

1.3 COLORECTAL SURGERY
1.3.1 The subspecialty field of Colorectal Surgery generally covers

diseases of the small bowel, colon, rectum and anal canal.
1.3.2 The scope of Colorectal Surgery is as per General Surgical

Services; include Endoanal/rectal ultrasound, anal manometry,
pudendal nerve latency tests and biofeedback services. Refer
to Section II, Chapter 5.
1.3.3 The Colorectal unit is involved in training and education of

nurses/AMOs, HOs, MOs, specialist and colorectal trainees.

surgeon is as per Section V, Table 3.
1.4 HEPATOPANCREATOBILIARY SURGERY (HPB)
1.4.1 HPB Surgery in the MOH is a dedicated tertiary care service,

which provides comprehensive clinical care to patients with
diseases of the liver, pancreas and biliary system.
1.4.2 The scope of HPB Surgery is as per General Surgical Services.

Refer to Section II, Chapter 5.
1.4.3 HPB Surgery Services will be provided in hospitals identified by

MOH. [1]

1.4.4 General surgeons should be able to do damage control
surgery for HPB trauma especially liver trauma, which includes
perihepatic packing, and haemorrhage control. Subsequently,
management should be discussed together with the nearest
HPB surgeon, based on the hemodynamic stability of the
patient.
1.4.5 General surgeons performing ERCP need to be trained and

credentialed at a high-volume centre.


1.5 UPPER GASTROINTESTINAL SURGERY
1.5.1 The Upper GI surgery covers the field of benign and malignant
diseases of oesophagus, stomach and duodenum. Surgical
management of morbid obesity and clinical nutrition are also a
component of this subspecialty.
1.5.2 The scope of Upper GI Surgery is as per general surgical

services, including Bariatric Programme and GI laboratory to
study motility disorder & reflux diseases. Refer to Section II,
Chapter 5.

1.6 THORACIC SURGERY
1.6.1 The Thoracic Surgery Services manage surgical problems

related to the disease of the chest wall, lungs, pleura,
mediastinum, trachea, bronchus, oesophagus and diaphragm.
1.6.2 The scope of Thoracic Surgery Service is as per General

Surgical Services. Refer to Section II, Chapter 5.

1.7 TRAUMA AND BURNS
1.7.1 Trauma & Burns care is provided in MOH hospitals.
1.7.2 The management of trauma will follow ATLS principle.
1.7.3 Provision of trauma care services shall be as per National

Trauma Policy when available.
1.7.4 Burns care maybe provided by the general or plastic surgeon.


2. Specialty Services
2.1 PAEDIATRIC SURGERY
2.1.1 The field of Paediatric Surgery in Malaysia generally covers,

surgical diseases affecting children below the age of 12 except
those areas generally covered by other surgical subspecialties
(e.g. Neurosurgery, Cardiac Surgery, Orthopaedics and Surgery
in the facial region).
2.1.2 Thoracic Surgery in children also undertaken by paediatric

surgeons rather than by cardiothoracic surgeons.
2.1.3 It is an extremely general field as it is determined by age rather

than organ specific.
2.1.4 There exist many similarities between General Surgery in adults

and children, but there are also specific differences especially
in the field of Neonatal Surgery.
2.1.5 It must be appreciated that surgeon caring for surgical children

must work closely with the Paediatricians, and much of the
referrals would come from them.
2.1.6 Currently Paediatric Surgical Specialist is only present in the

following MOH hospitals. [1]
2.1.7 Provision of services where Paediatric Surgery is available on

site is the areas of responsibility of a Paediatric Surgeon which
includes General Paediatric Surgical wards, clinic, operation
theatres, neonatal ICU (in collaboration with Neonatologists).
2.1.8 It would be expected that the Paediatric Surgery Services would

take overall care of the surgical needs of the children, including
neonates. Given adequate numbers of Paediatric Surgeons,
this should not pose a major problem.
2.1.9 There should be provision for rotation amongst the general

surgery trainees and junior specialists so that they are more
exposed to the differences in handling surgical children.

2.1.10 Services may include the “Travelling Surgical Team” to handle
Emergency Surgeries where the patient could not be easily
transported especially ill neonates on ventilators with NEC or
CDH. Currently these services are now provided within the
Klang Valley hospitals from HKL and from the regional centres
to major hospitals provision of services where paediatric
surgeon is NOT available on site.
PRACTICE POINT 11
2.1.11 There will be a need for general surgeons to initially handle

surgical children in hospitals where no paediatric surgeons are
available on site especially in emergency cases. Familiarisation
with paediatric surgery during the master’s in general surgery
training should serve as a template, but this would have to
continue during the training period of a junior general surgeon.
2.1.12 Common conditions that will be seen by general surgeons in

these centres.
(a) Appendicitis
(b) Intussusception
(c) Inguinal Hernia
(d) Child with abdominal and multi-organ trauma
(a) Appendicitis
PRACTICE POINT 12
• A trained general surgeon should be competent to diagnose,

manage and undertake surgery for most children more than
7 years old. If anesthesia support, facilities and OT staff are
available, this should be carried out in the facility. As this
condition is relatively uncommon in those below that age,
discussion with the nearest Paediatric Surgical Unit would
be prudent in the management and may require transfer to
those centres.
(b) Intussusception
AUDIT POINT 1
• Hydrostatic Reduction is the preferred modality of treatment

for intussusception, failing which surgery should be offered.
There should be an audit mechanism to look at the success
rate of hydrostatic reduction and corrective actions should
be taken if it falls below the National Standards.

(c) Inguinal Hernia
PRACTICE POINT 13
• This typically occurs in infants and can lead to

unnecessary transfers after hours. Ideally, all hernias in
premature babies and under 1 year old should be done
as quickly as possible to lessen this risk.
PITFALL
 Referral of neonates with reducible
inguinal hernia is often delayed.
• If the Networking visit does not allow this, these patients

should be referred early to the nearest Paediatric Surgery
Unit.
PRACTICE POINT 14
• All Inguinal hernia cases under 2 years old should be

done by paediatric surgeon and cases above 2 years
old can be done by general surgeon.
• The practice of waiting to do herniotomies until certain

weight (e.g. 10kg) is not ideal and may lead to being
incarcerated. Attempts at manual reduction, if done
correctly, should be successful in about 99% and should
only be attempted by experienced personnel.
(d) Child with abdominal and multi-organ trauma.
• Most children with solid organ injuries due to blunt

abdominal trauma can be managed non-operatively
provided resuscitation is done adequately. A CT scan is
usually needed to determine the extent of injuries and
is usually necessary in the absence of an experienced
Paediatric Radiologist, Managed Care Network, which
includes discussion with the Paediatric Surgical unit, would
ideally help to avoid unnecessary surgery in these children.
• Privilege to surgical procedure that should be provided by

the surgeons is as per Section V, Table 8.

2.2 NEUROSURGERY
2.2.1 Severe head injury is a neurosurgical emergency. Based on the

concept “Time is Neuron”, neurosurgical intervention should be
done early.
2.2.2 Neurosurgical intervention:
(a) In hospitals with Neurosurgeon:
• All neurosurgery cases will be managed by the

neurosurgeon.
(b) In hospital without Neurosurgeon: *
• The General Surgeon may perform burr hole/

craniotomy craniectomy for EDH & SDH excluding
posterior fossa bleeding. (*General Surgeon may
need training to provide the service).
Hospital with CT-scan Hospital without CT-scan

General Surgeon
shall provide surgical Refer to nearest hospital
intervention for EDH & with CT scan.
SDH.
• Privilege to surgical procedure that should be provided

by the surgeons is as per Section V, Table 9.
2.3 UROLOGY
2.3.1 Management of urological condition:
(a) In hospitals with Urologist:
• All urology cases will be managed by the urologist.
(b) In hospital without Urologist:
• General Surgeons are expected to provide basic

Urology Services. In whatever scope it is provided, the
surgeon must provide appropriate care and must have
undergone some form of training.
• Privilege to surgical procedure that should be provided

by the surgeons is as per Section V, Table 10.

SECTION IV
Appendices
“The patient is the centre of the medical universe

around which all our works revolve and towards
which all our efforts trend.”
J.B Murphy 1857-1916, Professor of Surgery,

Northwestern University, Chicago, Illinois, USA
APPENDIX 1
ORGANIZATION CHART
GENERAL SURGICAL SERVICES
MOH Head of General Surgical

Services
State Head of General Surgical Services
HOD of General Sugery Hospital Director

(Hospital with surgery) (Non-specialist hospital)

APPENDIX 2
TERMS OF REFERENCE OF GENERAL SURGEON
1 In the Ministry of Health, General Surgeons is gazetted by the Director

General of Health, as stated under ‘Perintah 27, Bab F’ of the General
Order (Perintah-Perintah Am) effective on 1ST March 1974.
2 Being a core specialty discipline, General Surgery Services have been a

vital requirement for a full-service hospital to function. The role of General
Surgeons has evolved greatly over the last few decades. From a historically
diverse specialty broadly covering head and neck, breast, thorax, abdomen
and gastrointestinal, paediatric, oncology and trauma, it has been gradually
defined as a core surgical specialty covering Trauma and Burn Surgery,
Breast and Endocrine Surgery, Colorectal Surgery, Upper Gastrointestinal
Surgery, Hepatopancreatobiliary Surgery, Vascular Surgery and Thoracic
Surgery.
3 Roles of General Surgeons:
3.1 In the Ministry of Health, the role of a General Surgeon is largely

defined based on the type of institution or the level of hospital he or
she serves in.
3.2 In all Minor Specialist Hospitals and many Major Specialist

Hospitals where other main surgical specialties such as Urology,
Paediatric Surgery, Neurosurgery and Plastic Surgery are not
available, General Surgeons assume the role of a Generalist in
Surgical Practice and provide care for patients with all spectrum
of surgical disorders, especially in management of acute surgical
emergencies, while providing consultation and elective surgeries
for a broad variety of cases under the General Surgery Specialty.
3.3 In many other Major Specialist Hospitals and State Hospitals, where
other main surgical specialties are available, General Surgeons
will assume the role of a specialist covering the field of General
Surgical Specialty. Further training permits General Surgeons
to focus in areas of subspecialties under General Surgery as
mentioned in section III (Subspecialty and Specialty Services).

4 Responsibilities of General Surgeons:
4.1 To lead and plan the management of patients under General

Surgery.
4.2 To conduct daily ward rounds to ensure in-patients receive

optimal treatment.
4.3 To conduct surgical outpatient clinics for new and follow-up

cases.
4.4 To review patients referred to General Surgery from Emergency

Department and patients from other disciplines.
4.5 To examine and evaluate patients for purpose of insurance,

PERKESO and KWSP.
4.6 To carry out on call duties as directed by the hospital director.
4.7 To plan and perform all surgeries under elective and emergency
operating theatre. All elective cases under major, minor and day
care operating theatre comes under the direct responsibility of
surgeons.
4.8 To supervise and guide medical officers credentialed to perform

certain surgical procedures/operations.
4.9 To be directly involved in training and supervision of house officers

and medical officers of the department. This will include teaching
sessions and continuous medical educations activities planned
to suite each level of training, i.e. house officers, junior medical
officers, surgical residents/Master of Surgery candidates.
4.10 To assist the head of department in conducting activities for

quality assurance, audits and assessments of medical staffs.
4.11 To assist in administrative tasks as delegated by the head of

department and involve in various committees and task forces
set up by the hospital director.

APPENDIX 3
TERMS OF REFERENCE OF HEAD OF THE DEPARTMENT
1 All Head of the Departments shall receive mandatory training in

administration to effectively manage and lead the General Surgery
Services in a hospital.
2 The General Surgery Service within a hospital shall, at all-time be

administratively managed by the Head of Department of General
Surgery who is a gazetted General Surgeon (according to the
gazettement criteria of MOH).
The roles include:
2.1 Responsible for the management of all the components of

the General Surgical Services, namely administrative, clinical
services and training.
2.2 Each General Surgery Department shall have their own

contingency plan. This plan must be available on board, to
address the issue of unexpected crisis.
2.3 Act as an advisor to the hospital director on matters pertaining

to General Surgical Services.
2.4 Responsible for planning, implementation and monitoring of the

surgical services and activities of the department in line with
national, state and hospital policies.
2.5 Work closely with the relevant stakeholders such as the Hospital
Director, Nursing managers and heads of other clinical services
in areas pertaining to the development and implementation of
the services. This includes participation in relevant task forces,
committees and quality assurance activities as planned by the
hospital director.
2.6 Responsible for the overall management of all the components

of department administration. In particular, matters pertaining to
the organisation, staff, asset, training, budget, development and
expansion.

2.7 General Surgery department activities and program shall be
under the scrutiny of the Head of Department and assisted by
the other Consultants, Surgeons and Medical Officers in the
Department. These include regular meetings with all department
personnel, continuous medical education activities, audits and
assessments of staff/clinical practices.
2.8 Work closely with Surgical OT sister, ward sister, and surgical
clinic sister. These nursing heads/sisters shall be responsible
for assisting the Head of Department in coordinating the nursing
service, activities and program in the department.
2.9 Act as a leader in clinical practices and provides professional

leadership and supervision for all members of the surgical team:
Surgeons, Medical Officers and House Officers.
2.10 Request for procurement of new or replacement equipment

shall be submitted to the National Head of General Surgery via
the Director and State Head of General Surgery.
2.11 Appropriate planning must be done in purchasing consumables

to ensure that services are provided without interruption.

APPENDIX 4
TERMS OF REFERENCE OF STATE HEAD OF GENERAL SURGICAL

SERVICES
1 Serves as the overall leader of the General Surgical Services in the

state.
2. The state Head of General Surgical Service shall ensure that current
national policies are being carried out to ensure smooth delivery of
General Surgical Services. He or she collaborates with the National
Head of General Surgery in formulating strategic plans for services,
development, policies and procedures.
3 Serves as clinical advisor to the State Director of Health in the planning

of development and expansion of general surgical specialty services in
all levels of health facilities i.e. state general hospital, district hospitals
and visiting district hospitals. Aspect of development involves human
resources, equipment and facilities.
4 Planning and implementation of training for all level of staffs involved in

the General Surgical Services.
4.1 Identify needs and training requirements of all surgeons in the

state.
4.2 Planning of mode of assessment for house officers and medical

officers under the state surgical service.
5 To provide input and planning for posting for adequate number of trained
surgeons in the state and ensure adequate coverage of each region of
the state in term of service.
6 Ensure smooth delivery of general surgical services by visiting general

surgeon to district hospitals without specialist.
7 If there is any unexpected crisis, the head must immediately inform the
Hospital Director and the National Advisor of General Surgical Services.
8 Provide input regarding acquiring assets in the field of general surgery

through out the state.

APPENDIX 5
TERMS OF REFERENCE OF MOH HEAD OF GENERAL SURGICAL

SERVICES
1 The Head of General Surgery is a gazetted general surgeon appointed

by the Director General of Health of Malaysia to assist the Ministry of
Health in the planning of the development of General Surgical Specialty
in MOH.
2 The roles and responsibilities of the Head of General Surgery are as

below:
2.1 Planning and recommending to Ministry of Health the

development and future direction of the specialty services, which
includes adequate distribution of infrastructures across the
nation to ensure accessibility and equality of services provided
by the ministry.
2.2 Planning of human resources, especially specialist manpower

to cater for the growing needs of hospitals /institutions of the
Ministry of Health. These include identifying future successors,
recommending promotions, human capital development (career
development of medical officers and specialist) and providing
feedbacks regarding gazettement of general surgeons.
2.3 Planning and recommendation of training requirement for

the specialty, monitoring the implementation of specialty/
subspecialty training programs and streamline training according
to the needs and development of the services.
2.4 Planning and conducting annual meetings with specialist within

the specialty at least once (1) a year.
2.5 Organising visits to each state on a regular basis.
2.6 Organising conferences within the specialty at least once (1) a

year.

APPENDIX 6
TERMS OF REFERENCE OF MOH HEAD OF SUB SPECIALTY
1 Report to the MOH Head of General Surgical Services.
2 Coordinate and provide direction for the development of its subspecialty,

in consultation with the MOH Head of General Surgical Services.
3 Develop, coordinate and facilitate the subspecialty training program.
4 Each subspecialty service shall be guided by the general policies and

procedures pertaining to the practice of surgery as well as special
requirements for its individual subspecialty.
5. The subspecialty service may function as a unit within the Department

of General Surgery when the patient case load within the unit is
sufficiently high and shall be headed by a trained consultant.

APPENDIX 7
TEMPLATE FOR OT LIST
UNIT:
HOSPITAL:
OPERATING LIST:
DATE: MONTH: YEAR: TIME:
CONSULTANT:
MEDICAL OFFICER:
NO NAME NRIC DIAGNOSIS PROCEDURE REMARK SURGEON CALLED IN

AGE/SEX/
WARD
ARRIVED OUT
General Surgical Services Operational Policy 2018

45
APPENDIX 8
Negotiated list and OT utilization:
Reference:
MINIT MESYUARAT BAGI MESYUARAT BERTUJUAN UNTUK

MENGOPTIMAKAN PERKHIDMATAN DEWAN BEDAH DI HOSPITAL-
HOSPITAL KEMENTERIAN KESIHATAN MALAYSIA.
(20 September 2016)/KKM.600-27/8/7(20) [5]
Kesimpulan Mesyuarat:
Perkara 2.17:
Long Elective OT List-Negotiated list
Mesyuarat dimaklumkan isu Long Elective OT List dan penyelesaiannya dengan

mengadakan Negotiated list telah dibincangkan di mesyuarat yang lepas
semasa mantan Ketua Perkhidmatan Pembedahan terdahulu. Senarai OT
yang dicadangkan oleh Pakar Bedah yang telah dibincangkan dan dipersetujui
oleh Pakar Anaesthesia hendaklah dihabiskan pada hari yang sama.
Mesyuarat dimaklumkan bahawa kebanyakan hospital tidak melaksanakan

saranan Negotiated List ini.
Kesemua ahli mesyuarat bersetuju bahawa dengan adanya OT time sehingga

12 jam dan bilangan kakitangan yang mencukupi, keperluan malaksanakan
Negotiated List ini mungkin kurang relevan.

APPENDIX 9
Recommendation for management of patient with peripheral vascular

complication requiring amputation.
Reference:
MINIT MESYUARAT KOORDINASI PERKHIDMATAN PELBAGAI DISIPLIN
KLINIKAL KEMENTERIAN KESIHATAN MALAYSIA (KKM), PERKHIDMATAN
PEMBEDAHAN AM (VASCULAR SURGERY) DAN PERKHIDMATAN
PEMBEDAHAN ORTOPEDIK.[6]
Management of peripheral vascular conditions including trauma

(14 October 2016)
Ahli mesyuarat telah bersetuju bahawa:
Perkara 4.2:
Pengurusan “Peripheral Vascular Disease with Gangrene Needing BKA or
AKA”
1. Kemasukan wad surgikal/ortopedik.
2. Untuk tahap amputasi (amputation level) akan diputuskan oleh Jabatan

yang menguruskan pesakit dengan atau tanpa CT angiogram.
3. Komunikasi antara jabatan berkaitan tidak harus melambatkan

pengurusan rawatan pesakit.
4. Selepas amputasi, Jabatan yang melakukan pembedahan tersebut

hendaklah meneruskan rawatan hingga pulih.
5. Rawatan rehabilitasi selepas amputasi akan di uruskan oleh Jabatan

Orthopedik.

APPENDIX 10
CONSENT FOR OPERATION/PROCEDURE

CONSENT FOR OPERATION/PROCEDURE

APPENDIX 11
PHOTOGRAPHY/MULTIMEDIA CONSENT FORM

APPENDIX 12
TESTIMONIAL LETTER OF REFUSAL OR TREATMENT/PROCEDURE

APPENDIX 13
KEY PERFORMANCE INDICATOR
GENERAL SURGERY
Optimal
NO Key Performance Indicators (KPI) Frequency
Target
Percentage of new non-urgent cases

that were given appointment for first
1 ≥75% Monthly
consultation within (≤) 4 weeks at
General Surgery Clinic.
Percentage of patients with waiting time
2 of ≤ 90 minutes to see the doctor at ≥90% 3 Monthly
General Surgery Clinic ≥ 90% 6 monthly
Post appendicectomy complications

3 rate during hospital stay. ≤10% Monthly
Percentage of cases with unplanned

return to the operating theatre within the
4 same admission following an elective ≤5% 3 Monthly
surgical procedure.
Percentage of colonic perforation

5 during colonoscopy. ≤2% 3 Monthly
Percentage of cancellation of elective

6 surgery. ≤10% Monthly
Percentage of complications following

7 thyroidectomy (hemi & total) for benign ≤10% 3 Monthly
thyroid diseases.
* Subject to the latest and updated indicators and its standard

BREAST AND ENDOCRINE SURGERY
Optimal
Target
Percentage of patients with waiting

1 time of less than 3 months for elective ≥ 90% Monthly
thyroidectomy.
Percentage of breast cancer patients

2 going for definitive surgery within (≤) 4 ≥75% 3 Monthly
weeks of the diagnosis.
Percentage of patients with suspicious

breast lump/lesion that were given
3 appointment within (≤) 14 working days ≥80% 3 Monthly
of referral at Breast clinic.
Percentage of patients with recurrent

4 laryngeal nerve (RLN) injury in primary ≤3% 3 Monthly
benign thyroid operation.
Percentage of patients with clear

5 surgical margins in Breast Conserving ≥75% 3 Monthly
Surgery (BCS).
Percentage of patients with missing

6 parathyroid gland in surgery for renal <20% 3 Monthly
hyperparathyroidism.

VASCULAR SURGERY
Optimal
Target
Post -operative mortality rate for
1 elective open repair of abdominal <10% 3 Monthly
aneurysm (AAA).
Percentage of patients undergoing
secondary amputation following
2 <40% 3 Monthly
intervention for critical limb ischemia
(CLI).
time of ≤ 90 minutes to see the doctor
3 ≥90% 3 Monthly
at General Surgery Clinic (General
Surgery).
Percentage of dialysis-access induced
4 limb ischemia following native arterio- <2% 3 Monthly
venous fistula creation.
Percentage of lower limb ischemia
5 following an elective open abdominal <1% 3 Monthly
aortic aneurysm repair.
return to the operating theatre within
6 the same admission following an ≤10% 3 Monthly
elective surgical procedure (General
Surgery).

COLORECTAL SURGERY
Optimal
Target
Rate of immediate stoma revision
1 after its creation. <20% 3 Monthly
Percentage of patient with waiting

2 time of ≤ 3 weeks for colorectal cancer ≥90% 3 Monthly
(CRC) surgery.
3 time of ≤ 4 weeks for elective ≥90% 3 Monthly
colonoscopy.
Rate unclear surgical margins in
4 rectal cancer surgery. <10% 3 Monthly
Percentage of colonic perforation

5 during colonoscopy. <2% 3 Monthly
Occurrence of anal stenosis following

6 haemorrhoidectomy. 0 3 Monthly

HEPATOPANCREATOBILLIARY SURGERY
Optimal
Target
Percentage of non-urgent cases
1 that are given appointment for first ≥75% 3 Monthly
consultation within 1 month.
2 time ≤ 1 month for elective surgery for ≥90% 3 Monthly
hepatobiliary malignancy.
Percentage of cancellation of listed

3 <10% 3 Monthly
elective hepatobiliary surgical cases.
Mortality ≤ 30 days following elective

4 ≤5% 6 Monthly
Hepatic Resection.
Mortality ≤ 30 days following elective

5 ≤5% 3 Monthly
Whipple’s operation.
Percentage of attendance for

6 ≥80% Monthly
department CME.

UPPER GASTROINTESTNAL SURGERY
Key Performance Indicators Optimal

NO Frequency
(KPI) Target
Percentage of oesophageal or gastric

1 cancer patients with clear surgical margin ≥75% 3 Monthly
in curative resection.
Percentage of patients with oesophageal

2 or gastric cancers operated within (≤) 3 ≥75% 3 Monthly
weeks after pre- operative optimization.
Percentage of symptomatic patients

3 referred to Upper GI team to undergo ≥75% Monthly
Upper GI endoscopy within (≤) 6 weeks.
Percentage of patients with anastomotic

4 <30% 6 Monthly
leak after oesophageal surgery.
Percentage of patients with gastric cancer

undergoes curative surgical resection
5 ≥70% 6 Monthly
which ≥ 15 lymph nodes resected and
pathologically examined.
Percentage of patients with benign

stomach disorder who undergo elective
6 <15% 6 Monthly
surgery transfused with more than 4 units’
blood intra-operatively.

THORACIC SURGERY
Optimal
Target
Percentage of elective thoracotomy
1 <2% 3 monthly
wound infection.
Percentage of chest drain related
2 <2% 3 monthly
complications.
Percentage of stump leak following
3 <5% 6 monthly
elective lobectomy or pneumonectomy.
Percentage of patients with
respectable and operable thoracic
4 >90% 3 monthly
malignancy operated within 3 weeks
of diagnosis.
Percentage of diagnosed thoracic
empyema referred for surgical
5 >75% 3 monthly
intervention within 2 weeks of
diagnosis.

TRAUMA AND BURNS
Optimal
No Key Performance Indicators (KPI) Frequency
target
Timeliness for crash operation within
1 ≥75% 3 Monthly
(≤) 60 minutes.
2 Minor trauma mortality rate. <8% 3 Monthly
3 Severe Burn Mortality Rate (BURN). <30% 3 Monthly
Percentage for non-therapeutic

4 laparotomy (NTL) for trauma cases <20% 3 Monthly
(TRAUMA).
Percentage of trauma alert responded
5 >75% 6 Monthly
by surgeon within (≤) 30 minutes.
Percentage of patients with duration of
6 surgery within (≤) 90 minutes in crash >75% 3 Monthly
trauma laparotomy.
return to the operating theatre within
7 the same admission following an ≤10% Monthly
elective surgical procedure (general
Surgery).

APPENDIX 14
PRACTICE POINTS, AUDIT POINTS AND PITFALLS
Practice point (PP)

• Formatting the product of focus of implementation.
• This PP generally mandatory to be implemented in every department.
• Process which should be in place in all surgical departments that
reflect good practice and patient centered.
Pitfall (PF)
• Common shortfalls in such process are highlighted in the pitfalls (PF).
Audit point (AP)

• Should be used to facilitate and improvement in terms of performance
of the centers.
• All HODs are encouraged to audit & improve the outcome of their
hospital process of care.

PRACTICE POINT 1 PITFALL
 Date of appointment shall be determined by  Triaging done by

an MO after reviewing the referral letter. paramedics may result
 Based on the urgency of the case, patient delay of appointment
may be seen on the same day. for urgent cases.
PRACTICE POINT 2
 Patients suspected of having malignancy
should be given an early appointment
(within2 weeks). The management of these
cases should be specialist-led.
PRACTICE POINT 3
 There should be a system in place to trace
patients with malignancy who defaults.
PRACTICE POINT 4
 The overall care of patients in the surgical
wards shall be under the responsibility of a
consultant or specialist.
PRACTICE POINT 5
 A specialist should review and be involved in
the management of all critically ill patients.
PRACTICE POINT 6
 Patients who were
 Appointment for follow up should be given
discharged over the
upon discharge, and in the event where
weekend were made to
this is not feasible, the staff should call the
call back for a follow up
patient and inform the appointment date.
appointment.
PRACTICE POINT 7
 The name of the consultant/surgeon in
charge of the theatre must be specified in
the list. He shall determine the sequence
of the cases and their respective theatres.

 In the event of overwhelming number  Information about long

of emergency, elective surgeries emergency list not brought
should be postponed to accommodate to the attention of the
them. (responsibility of the HOD) surgical/anaesthesiology
HOD to reprioritize the
utilization of operation
theatre.
 Absence of a contingency
plan to clear long
emergency list especially
after hours and during
public holidays.
PRACTICE POINT 9
 All surgeons should follow the “Safe  Surgeons are known to skip
Surgery Save Lives” guideline. the TIME OUT.
PRACTICE POINT 10
 Breast cancer patients, where feasible
should be managed through MDT.
PRACTICE POINT 11
 There will be a need for general
surgeons to initially handle surgical
children in hospitals where no
paediatric surgeons are available on
site especially in emergency cases.
Familiarisation with paediatric surgery
during the master’s in general surgery
training should serve as a template,
but this would have to continue during
the training period of a junior general
surgeon.

PRACTICE POINT 12
 A trained general surgeon should be

competent to diagnose, manage and
undertake surgery for most children
more than 7 years old. If Anaesthesia
support, facilities and OT staff are
available, this should be carried out
in the facility. As this condition is
relatively uncommon in those below
that age, discussion with the nearest
Paediatric Surgical Unit would be
prudent in the management and may
require transfer to those centres.
 This typically occurs in infants and

can lead to unnecessary transfers
 Referral of neonates with
after hours. Ideally, all hernias in
reducible inguinal hernia is
premature babies and under 1 year
often delayed.
old should be done as quickly as
possible to lessen this risk.
PRACTICE POINT 14
 All Inguinal hernia cases under 2

years old should be done by paediatric
surgeon and cases above 2 years old
can be done by general surgeon.
AUDIT POINT (AP)
AUDIT POINT 1
Hydrostatic Reduction is the preferred modality of treatment for
intussusception, failing which surgery should be offered. There should
be an audit mechanism to look at the success rate of hydrostatic
reduction and corrective actions should be taken if it falls below the
National Standards.

SECTION V
List of procedures
One of my surgical giant friends had in his

operating room a sign
“If the operation is difficult, you aren’t doing it
right”. What he meant was you have to plan every
operation, you cannot ever be casual, and you have
to realize that any operation is a potential fatality.
Joseph E Murray 1919-2012, American Surgeon

TABLE 1: BREAST & ENDOCRINE SURGERY
GENERAL SURGEON SUBSPECIALTY
1. Wide local excision 1. Sentinel lymph node biopsy

2. Mastectomy with axillary dissection 2. Oncoplastic breast surgery *
3. Microdochectomy 3. Breast implants
4. Hook wire localization 4. Various types of volume displacement maneuvers & mastopexy e.g.
5. Hemithyroidectomy Grisotti Mastopexy)
6. Total thyroidectomy 5. Breast reconstruction using flaps (e.g. LD flaps)
7. Sistrunk operation 6. Retrosternal Goitres
7. Secondary thyroidectomy
8. Neck dissections
9. Endoscopic thyroidectomy **
10. All parathyroid surgery
11. All adrenal surgery
NOTE:
* Only to be done by BNE surgeons received training in Oncoplastic Breast
procedures
** Only to be done by BNE surgeons received training in endoscopic thyroidectomy

procedures

67
68
TABLE 2: VASCULAR SURGERY
1. Venous access i.e. chemo port insertion 1. All vascular surgical procedures.
2. High saphenous vein ligation
3. Femoral embolectomy
4. Creation of AVF
5. Vascular repair in trauma

TABLE 3: COLORECTAL SURGERY
1. Right hemicolectomy 1. Ultra-low anterior resections

2. Extended right hemicolectomy 2. Delorme’s procedure
3. Left hemicolectomy 3. Coloanal anastomosis
4. Simple FIA 4. PPILA
5. Lateral Sphincterotomy 5. Recurrent & complex FIA
6. Small bowel resection 6. Rectovaginal fistula
7. Meckel’s diverticulectomy Emergency 7. Sphincter injury secondary to trauma
8. Obstetric sphincter repair 8. Rectopexy with or without resection (open or laparoscopic)
9. Subtotal colectomy with ileorectal anastomosis 9. STARR
10. 10.Hartmann’s procedures open & 10. Laparoscopic LAR/ULAR/APR
11. laparoscopic colostomy or ileostomy 11. Pelvic exenteration , TEMS
12. Anterior resection 12. LIFT
13. Open haemorrhoidectomy
14. Reversal of Hartmann’s
15. APR
16. LAR
17. Altmeier procedure
18. Laparoscopic colorectal surgery (excluding LAR /
ULAR/ /APR)

69
70
TABLE 4: HEPATOPANCREATOBILIARY SURGERY
1. Open cholecystectomy 1. Whipples surgery

2. Laparoscopic cholecystectomy 2. Elective liver resection
3. CBD exploration 3. CBD injury
4. Splenectomy 4. Choledochal cyst resection (type 3, type 4 & type 5)
5. Distal pancreatectomy 5. All pancreatic surgery (excluding distal

6. Emergency non -anatomical liver pancreatectomy)
resection in trauma
7. Choledochal cyst resection
(type 1 and type 2)
TABLE 5: UPPER GASTROINTESTINAL SURGERY
1. Underrunning of Upper GI bleeding. 1. Open/Laparoscopic Radical Distal/ D2 Subtotal Gastrectomy

2. Repair of Perforated Duodenal/Gastric 2. Open/Laparoscopic Radical/ D2 Total Gastrectomy
Ulcer. 3. Radical Esophagectomy with 2 or 3 Field Lymphadenectomy for Esophageal
3. Open Feeding Gastrostomy. Cancer eg. Ivor-Lewis, Thoracoabdominal, McKeown Esophagectomy etc.
4. Feeding Jejunostomy. 4. Esophageal Replacement/ Reconstruction Surgeries eg. Gastric pullthrough,
5. Gastrojejunostomy Bypass Procedure.
Jejunum or Colonic interposition, Esophageal Repair, Enucleation of Esophageal
6. Open Partial Gastrectomy/Antrectomy for
emergency life-threatening condition. Smooth Muscle Tumour or Duplication Cyst etc
7. Open Pyloroplasty. 5. Laparoscopic Anti-reflux & Hiatal Surgeries(full or partial wraps)
8. Open Gastric GIST Resection. 6. Surgeries for Esophageal Motility Disorder eg. Laparoscopic Myotomy
9. Open Partial/Distal Gastrectomy/ Cardiomyotomy + Anti-reflux procedure etc.
Antrectomy* 7. Bariatric & Metabolic Surgeries Eg. Laparoscopic Sleeve Gastrectomy,
10. Open Total Gastrectomy* Laparoscopic RY Gastric Bypass etc.
11. Open Gastric Wedge Resection* 8. Laparoscopic Gastric GIST Resection
12. Open D2 Subtotal/total Gastrectomy.
13. Bariatric & Metabolic Surgeries.
NOTE:
*Subject to the intention to treat. A more radical surgeries and pre-operative oncology management should be performed at
subspecialty unit for malignant pathology with potential curative resection.

71
72
TABLE 6: THORACIC SURGERY
1. Emergency Thoracotomy for Massive Hemothorax. 1. VATS/Open Lobectomy

2. VATS/Open Decortication 2. VATS/Open Sleeve Lobectomy
3. VATS/Open Peripheral Lung Biopsy 3. Pneumonectomy
4. VATS Sympathectomy 4. Tracheobronchial/Carinal Resection & Reconstruction
5. VATS/Open Thymectomy
6. VATS/Open Mediastinal mass excision
7. Central Lung Biopsy
8. VATS/Open Ligation of Thoracic Duct

9. Chest Wall Resection &Reconstruction
10. Pleural Window
11. Pericardial Window
TABLE 7 : TRAUMA AND BURN
1. SSG 1. Vascular injury repair

2. All live saving procedures in trauma
TABLE 8 : PEDIATRIC SURGERY
GENERAL SURGEON SPECIALTY
1. Herniotomy
2. Orchidectomy
3. Emergency laparotomy
4. Appendicectomy
5. Intussusception

73
74
TABLE 9 : NEUROSURGERY
1. Emergency craniotomy for subdural & extra-dural

haemorrhage.
2. Burr hole.
3. EVD insertion

TABLE 10 : UROLOGY
1. Cystoscopy
2. Insertion of ureteric stent
3. Emergency nephrectomy
4. Operation for hydrocele
5. High ligation orchidectomy
6. Orchidopexy
7. Repair of ureteric and bladder injury
8. Vesicolithotomy
TABLE 11
LIST OF PROCEDURE (MEDICAL OFFICERS)
NO DURATION OF PROCEDURES
TRAINING
1 PHASE I MEDICAL - CENTRAL VENOUS LINE

OFFICER INSERTION
(LESS 6 MONTHS) - CHEST TUBE INSERTION
- ENDOTRACHEAL INTUBATION
- INCISION AND DRAINAGE OF
SUBCUTANEOUS INFECTIONS
- TOILET & SUTURING
- THRUCUT BIOPSY
- SANGSTAKEN BLAKEMORE TUBE
INSERTION
2 PHASE II MEDICAL - SEBACEOUS CYST EXCISION

OFFICER - LIPOMA EXCISION
( 6 – 18 MONTHS) - APPENDICECTOMY
- BENIGN BREAST LUMP EXCISION
- CIRCUMCISION
- INGUINAL HERNIOPLASTY ( GA/
REGIONAL/LA)
- OPEN & CLOSE ABDOMEN
- SAUCERISATION
- SECONDARY SUTURING
3 PHASE III MEDICAL - LAPARATOMY FOR PERFORATED

OFFICER APPENDICITIS WITH PERITONITIS
(18-30 MONTHS) - LYMPH NODE BIOPSY
- ORCHIDECTOMY
- JABOULAYS PROCEDURE
- PERFORATED GASTRIC ULCER
REPAIR
- STOMA CREATION
- TRACHEOSTOMY
- OPEN MAYOS REPAIR

4 PHASE IV MEDICAL - JEJUNOSTOMY
OFFICER - LAPAROSCOPIC
( >30 MONTHS) APPENDICECTOMY
- SMALL BOWEL RESECTION &
ANASTOMOSIS
- SPLENECTOMY
- HIGH SAPHENOUS VEIN LIGATION
& VENOUS STRIPPING ( WITH STAB
AVULSIONS)

REFERENCES:
1. Speciality and Subspecialty Framework of Ministry of Health Hospitals

under 11th Malaysia Plan (2016-2020).MOH/P/PAK/324.16 (bk) www.
moh.gov.my
2. Guideline of Prioritisation of Cases for Emergency and Elective Surgery

in Ministry of Health Malaysia 2018. www.moh.gov.my
3. Polisi Perkhidmatan Rawatan Harian di Hospital-Hospital Kementerian

Kesihatan Malaysia 2016. MOH/P/PAK/316.17 (BP) www.moh.gov.my
(penerbitan_ Perkhidmatan Rawatan Harian_polisi)
4. Day Care Surgery Standard Operating Procedure 2016. MOH/P/

PAK/316.16 (GU). www.moh.gov.my (penerbitan_Perkhidmatan
Rawatan Harian_garispanduan)
5. Minutes of meeting: Minit Mesyuarat bagi mesyuarat bertujuan

untuk mengoptimakan perkhidmatan dewan bedah di hospital-
hospital Kementerian Kesihatan Malaysia.
Rujukan:KKM.600-27/8/7 (20) 20 September 2016 www.moh.gov.my
(penerbitan_bedah am_rujukan)
6. Minutes of meeting: Mesyuarat Koordinasi Perkhidmatan Pelbagai Disiplin

Klinikal Kementerian Kesihatan Malaysia Perkhidmatan Pembedahan
Am (Vascular) dan Perkhidmatan Pembedahan Ortopedik- management
of peripheral vascular conditions including trauma 14 Oktober 2016.
www.moh.gov.my (penerbitan_bedah am_rujukan)
7. Guidelines on Safe Surgery Saves Lives Programme. Patient Safety Unit

Medical Care Quality section, Medical Development Division, Ministry of
Health Malaysia 2018. www.moh.gov.my
8. Pemantapan tatacara tugas atas panggilan (ON-CALL) pegawai

perubatan pakar di hospital dan institusi perubatan Kementerian
Kesihatan Malaysia. Rujukan; KKM.600-20/2/1(23). www.moh.gov.my
(penerbitan_bedah am_rujukan)
9. Guideline for Credentialing & Privileging in the Ministry of Health

Malaysia. Medical Development Division. December 2001 www.moh.
gov.my

10. Malaysian Medical Council Guideline: Consent for treatment of patients
by registered medical practitioners.[Adopted by the Malaysian Medical
Council on 21 June 2016]. First Revision: 19 September 2017.
11. General Hospital Operational Policy. Medical Development Division

Ministry of Health Malaysia. MOH/P/PAK/268.13(BP). First Edition
August 2013.
12. Directive: Pekeliling Ketua Pengarah Kesihatan Bil 2/2009. Garispanduan

Rujukan dan Perpindahan Pesakit di antara hospital-Hospital
Kementerian Kesihatan Malaysia. Bahgian Perkembangan Perubatan.
Kementerian Kesihatan Malaysia. MOH/P/PAK/165.08 (GU) Mei 2009
www.moh.gov.my (penerbitan _bedah am_rujukan)
13 Letter: Arahan Pemantauan Petunjuk Prestasi Utama (KPI) Hospital

Performance Indicator for Accountability (HPIA) dan KPI Perkhidmatan
Klinikal Bagi Program Perubatan yang telah dikemaskini (Pindaan
Januari 2015). Rujukan: KKM.87/P3/12/6/14 (2).10 Februari 2015.
Clinical Audit Unit, Medical Care Quality Section, Medical Development
Division, MOH
14. Letter: Penghasilan Borang-Borang Keizinan yang baru melalui Projek

Pembangunan Modul Clinical Documentation (CD). Rujukan: KKM.100-
11/1/67 JLD 2 (1). 18 November 2016. www.moh.gov.my (penerbitan_
bedah am_rujukan)
15. Letter: Penjelasan Lanjut Borang-Borang Keizinana yang baru dari

Projek Pembagunan Modul Clinical documentation (CD) Peringkat
Kementerian Kesihatan Malaysia. Rujukan: 100-11/1/67 JLD 2(40). 15
Mac 2017. www.moh.gov.my (penerbitan_bedah am_rujukan)
16. Global Surgery 2030: Evidence and solution for achieving Health,
welfare, Economic Development was written by The Lancet Commission
on Global Surgery, an international multi-disciplinary group of 25
Commissioners, in consultation with collaborators in over 110 countries
and all major regions of the world.

LIST OF ABREVIATIONS :
MOH Ministry of Health

HOD Head of the Department
WHO World Health Organization
GSWI General Surgeon with Interest
TOR Term of Reference
MO Medical Officer
MIS Minimaly Invasive Surgery
CI Clinical Issues
OGDS Esophagogastroduodenoscopy
ERCP Endoscopic Retrograde Cholangiopancreatograp hy
OT Operation Theater
HPB Hepatopancreatobiliary
DG Director General
MMC Malaysian Medical Council
e – POMR Electronic Problem Oriented Medical Record
KPI Key Performance Index
NSR National Specialist Register
B&E Breast and Endocrine
HOs House Officers
MOs Medical Officers
AMOs Assistant Medical Officers
GI Gastro Intestinal
ATLS Advanced Trauma Life Support
ICU Intensive Care Unit
NEC Necrotising Enterocolitis
CHD Congenital Heart Disease
HKL Hospital Kuala Lumpur
CT-scan Computerized tomography scan
EDH Extra Dural Haemorrhage
SDH Subdural Hemorrhage
KWSP Kumpulan Wang Simpanan Pekerja
PERKESO Pertubuhan Keselamatan Sosial
NRIC National Registration Identity Card
GIT Gastro Intestinal Tract
OI Operational Issues
MDT Multidisciplinary team
UGI Upper Gastrointestinal
FIA Fistula in Ano
GIST Gastrointestinal Stromal Tumor
CBD Common Bile Duct
AVF Arteriovenous Fistula
APR Abdominoperineal Resection
LAR Low Anterior Resection
ULAR Ultra Low Anterior Resection

PPILA Pan proctocolectomy with ileoanal anastomosis
STARR Stapled Transanal Resection of the rectum
TEMS Transanal Endoscopic Micro-surgery
LIFT Ligation of Intersphincteric Fistula Tract
LD Flap Latissimus Dorsi flap
VATS Video Assisted Thoracoscopic Surgery
SSG Split Skin Grafting
EVD External Ventricular drain
RLN Recurrent laryngeal nerve
BCS Breast Conserving Surgery
AAA Abdominal aortic aneurysm
CLI Critical Limb Ischemia
CRC Colorectal cancer
CME Continuining Medical Education
NTL Non-therapeutic laparotomy
PP Practice Point
PF Pitfall
AP Audit Point

“To study the phenomenon of disease without
books is to sail an uncharted sea, while to study
books without patients is not to go to sea at all.”
Sir William Osler 1849-1919, Professor of Medicine,

Oxford
ISBN 978-967-2173-12-0
MINISTRY OF HEALTH MALAYSIA
BLOCK E1, PARCEL E,
FEDERAL GOVERNMENT ADMINISTRATIVE CENTRE
62590 PUTRAJAYA
MALAYSIA
TEL: 603 8883888 9 789672 173120
http://www.moh.gov.my

General Surgical Services Operational Policy

Uploaded by

Copyright:

Available Formats

General Surgical Services Operational Policy

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

General Surgical Services Operational Policy

Uploaded by

Copyright:

Available Formats

MOH/P/PAK/389.

MEDICAL DEVELOPMENT DIVISION

GENERAL SURGICAL SERVICES OPERATIONAL POLICY

A catalogue record of this document is available from the

Institute for Medical Research

National Library of Malaysia

Softcopy of the document is available at www.moh.gov.my

Section I. Editorial board and contributors

Section II. The policy

General Surgical Services Operational Policy 2018 7

Section III. Subspecialty and specialty services

1.1 Breast and endocrine surgery 27

2.1 Paediatric surgery 31

Section IV. Appendices

8 General Surgical Services Operational Policy 2018

Section V. List of procedures

General Surgical Services Operational Policy 2018 9

Malaysia is proud of the strong foundations laid since independence in

We have now entered the consolidation phase of quality improvement

Operational policies are imperative therefore in ensuring a uniform delivery

I am pleased that this operational policy conforms to the highest

I hope this Operational Policy of General Surgical Services of Malaysia will

YBhg Datuk Dr Noor Hisham bin Abdullah

i General Surgical Services Operational Policy 2018

The preparation of the General Surgical Services Operational Policy was

It contains general outlines of scope of services provided, our direction and

This document has highlighted Practice Points and Pitfalls to address

As with all policy documents, it shall be reviewed.

YBhg Dato’ Dr Abdul Jamil bin Abdullah

General Surgical Services Operational Policy 2018 ii

The healthcare facilities also vary from one extreme of non-specialist

YBhg Dato’ Seri Dr Mohamed Yusof bin Haji Abdul Wahab

iii General Surgical Services Operational Policy 2018

“Wherever the art of medicine is loved,

General Surgical Services Operational Policy 2018 iv

Dato’ Dr Haji Azman bin Haji Abu Bakar

Dr Ahmad Razid bin Salleh

Datin Sri Dr Asmah binti Samat

Dr Mohd Fikri bin Ujang

Dr Paa Mohamed Nazir bin Abdul Rahman

Dr Patimah binti Amin

Dr Laili Murni binti Mokthar

General Surgical Services Operational Policy 2018 1

Dato’ Dr Abdul Jamil bin Abdullah

MEMBERS OF DRAFTING COMMITTEE

Dato’ Seri Dr Mohamed Yusof bin Haji Abdul Wahab

Dato’ Dr Jiffre bin Din

Dato’ Dr Wan Khamizar bin Wan Khazim

Dato’ Dr Nik Mohamad Shukri Nik Yahya

Datuk Dr Muhammad Safian bin Naim

Dato’ Dr Fitjerald Henry

Dr Nor Aina binti Emran

Dr Yan Yang Wai

2 General Surgical Services Operational Policy 2018

Dr Jasiah binti Zakaria

Dr Lewellyn Rajakumar Kovil George

Dr Lee Yuk Loong

Dr Kenneth Voon Kher Ti

General Surgical Services Operational Policy 2018 3

Datuk Dr Zainal Ariffin bin Azizi