Personal Preparations : Surgery Through Recovery

Once you decide to proceed with surgery, there are certain steps to take before your operation to ensure that you are in the best possible readiness for the procedure. Start taking chewable multivitamins once daily to improve your general health. You will need to take these every day for the rest of your life. Further, take 500 mg of Calcium three times daily. Vitamin and mineral intake is especially important after bariatric surgery in order to maintain good nutrition and health and you are at risk for deficiencies after surgery. We have found that if you start taking these supplements before surgery, it will be easier remembering them after surgery.

Another important way to prepare for surgery is exercise. The best time to begin your exercise program is before your surgery. Your weight loss after surgery is highly dependant on both your dietary habits and your level of exercise. The sooner you start exercising the easier it will be after you have surgery. It also helps improve circulation, which helps you through the surgical procedure. Success in gastric bypass is all about choosing the right habits before and after surgery. We want you to start moving more than normally; however, we do not want you injure yourself. Walking on a daily basis improves your circulation and makes breathing easier during recovery. You will also benefit from having a plan in place, so you don’t have to figure out your walking route during the recovery phase. Should you be unable to walk daily due to joint pain, then you may want to look into an aquatics program. Every town has classes for arthritic or cardiac patients that are held in a safe and clinical environment. Water exercises still condition your breathing, but are not weight bearing and are therefore easier for people who have joint problems. You can also practice the exercises that speed up your recovery and become familiar with the chapter on Exercise.

You should begin taking daily showers a few days before you enter the hospital. Careful attention must be given to cleaning the entire abdomen from the neck and armpits to the groin, making sure to clean between any folds of skin. Use antibacterial soap such as Dial. Pat dry any reddened areas or use a blow dryer on low heat to dry difficult to reach places.

Medications

It is important to avoid aspirin and all aspirin-containing medicines for 10 days prior to surgery. All herbal medications such as St. John’s Wort, Gingko Biloba, Garlic, etc, should be discontinued as well, as these also have blood-thinning properties. Other herbal supplements such as Kava Kava and Valerian Root are known to interact with anesthesia and should also be stopped 10 days before surgery. Again, remember to tell your surgeon all the medicines and herbal supplements you are taking. Do not forget to check the label of your multivitamin; many times they can contain herbal supplements as well. Remember to check all labels of over-the-counter medicines, since certain over-the-counter medicines can contain aspirin, too. If in doubt, please check with your pharmacist or your surgeon.

In conclusion, make sure that you keep your surgeon and other specialists informed of the complete list of medicines that you are taking. Include herbal supplement and vitamins in this list.

Alcohol and Tobacco

Since smoking hinders proper lung function; it can increase the possibility of anesthetic complications. Smoking can increase your risk of complications such as deep vein thrombosis (blood clots in the legs), and smoking also reduces circulation to the skin and impedes healing. Patients are required to quit smoking permanently before surgery. Smokers who undergo anesthesia are at increased risk for developing cardiopulmonary complications (pulmonary embolism, pneumonia and the collapsing of the tiny air sacs in the lungs) and infection as well. Besides the well-known risks to the heart and lungs, smoking stimulates the stomach acid production, leading to possible ulcer formation. In addition, smoking can cause a reduced ability of the body to heal itself.  This can lead to wound infections, hernias, and leaks that may be devastating.  Patients must agree to permanently refrain from smoking before and after surgery.

Remember, you are doing all of this to improve your health. It is also important to avoid alcohol since it causes gastric irritation and can lead to liver damage. Be aware that during periods of rapid weight loss the liver becomes especially vulnerable to toxins such as alcohol. You may find that only a couple of sips of wine can give you unusually quick and strong effects of alcohol intolerance. In addition, alcoholic beverages are essentially a carbohydrate or sugar based beverage high in sugar calories and may cause “dumping syndrome” and/or impede your weight loss. For these reasons, we recommend complete abstinence from alcohol for one year after surgery and avoiding frequent consumption thereafter.  It is important to understand that alcohol is a liquid calorie and is VERY calorie dense. It has almost as many calories per gram as fat.  It really works against long term successful weight loss.

Work and Disability

Expected return to work time is anywhere from one to six weeks. There is, of course, great variability. Gastric banding patients can usually expect faster recovery and return to work within one to two weeks. The time you take off from work depends on many things. These include the kind of work you do, your general state of health, how badly your work needs you, how badly you need your work, your general state of motivation, and your energy level. It is important to remember that one is not just recovering from surgery, but one is eating very little and losing weight rapidly. The first few weeks are a precious time to get to know your new digestive system, rest, exercise and meet with other post-operative patients in support group meetings. If financially feasible, take this time to focus on your recovery. Since these procedures are very commonly minimally invasive, the recovery time is more tied to the metabolic changes your body is undergoing instead of significant incisional pain.  The incisions are very small, but your body is learning how to burn fat efficiently in the first 2 weeks after surgery.  Once your body has adapted, patients go from having low energy, to having more energy than before surgery.

Some patients do not wish to tell the people with whom they work what kind of surgery they are having. It is perfectly appropriate to tell as much or as little to your employer as you would like. Although you do not need to tell your employer that you are having weight loss surgery, it is recommended to reveal that you are having major abdominal surgery. Explain that you will need four or more weeks to recover, especially if you would like to have some form of financial compensation during your absence. Your employer should have the relevant forms for you to complete. You may want to indicate that you will not be able to do any heavy lifting for several weeks after surgery.

Hospital Pre-Admitting Procedures

You will receive a call from a hospital nurse the day before your surgery instructing you on the time to come to the hospital and review the necessary surgical preparation. If your surgery is on Monday, you will be called on Friday. If you need to know your arrival time before receiving your nurse call, you are welcome to call 713-704-4375 after 9:00 a.m. (the day before surgery). Please keep in mind that the Memorial Hermann Hospital-Texas Medical Center (Day Surgery) is not open on Saturdays and Sundays.   If you are receiving surgery in another hospital or surgery center, then the day surgery unit of that facility should provide you answers to these questions.

If You Are Ill Before Surgery:

Should you develop a cold, persistent cough, fever or any changes in your condition during the days before your surgery, please notify the physician who medically cleared you for surgery. You will need to be re-evaluated for surgical readiness. You need to be in the best possible shape for anesthesia. Scheduling will be adjusted to your condition if necessary.

Personal Preparation

We recommend that you shower in the morning on the day of surgery, but do not use any moisturizers, creams, lotions or make-up. Remove your jewelry and do not wear nail polish. You may wear dentures, but you will need to remove them just prior to surgery. Please bring your eyeglasses and a case if possible.

Anesthesia:

When general anesthesia is induced; you will be sound asleep and under the care of your anesthesiologist throughout the operation. The anesthesiologist spends all of his or her time during the procedure ensuring your safety. Any significant changes in blood pressure, heart rate or other vital functions are treated immediately. Your anesthesiologist will discuss the specific risks of general anesthesia with you before your surgery. Be prepared for interviews by many nurses and doctors before surgery when you arrive. They will all ask you many similar or even the same questions. This is all done for your safety, not to annoy you. Rest assured that everyone is a professional and we are all here to help you. Certainly, if there is anything we can do to make your stay at the hospital more comfortable; please don’t hesitate to ask anyone.

The Operation

Once you enter the OR, the staff will do everything they can to make you feel safe and secure. You may be transported on a gurney (a bed or stretcher on wheels). In the OR, you will be anesthetized. Medicines that will make you drowsy will flow through the tubing into a vein in your forearm. Sometimes these medicines give a slight, brief, burning sensation as they’re given. At the same time, to ensure your safety, the anesthesiologist will connect you to monitoring devices.

After you are asleep, the anesthesiologist places a breathing tube, and a urinary catheter might be placed. The surgical procedure will usually last from about 1 hour to 4 hours depending upon the procedure performed.  The operations requiring more technical work (such as gastric bypass or biliopancreatic diversion) may take longer than the simpler operations (such as gastric band or gastric sleeve). The final length of the operation is dependent upon the number of extra procedures necessary, if any, and the difficulty of finding working space within a very large abdomen. Seldom is the length of operating time related to the patient’s immediate condition in the operating room, and it may go several hours without undue side-effects or risks. Your surgical team will take excellent care of you! When your surgery has been completed, you will be moved to the Recovery Room.

The Recovery

You will constantly be connected to monitoring equipment, and during this period, fully trained Recovery Room nurses will remain with you at all times. The nurses are certified for advanced cardiac life support. You can be confident that you will be well cared for in the Recovery Room. When your initial recovery is completed and all your vital signs are stable, you will be transported back to day surgery or to your room on a dedicated bariatric surgery unit. Patients are usually in the Recovery Room for about two hours before they are transported to their room. Your family will be able to see you when you arrive at your room. This may be 5 or 6 hours after they saw you preoperatively. The surgeon will go to the family waiting area to talk with your family as soon as the operation is finished. We prefer that family members wait in the hospital waiting area during the surgery.

Hospitalization

Adjustable band procedure may be an outpatient or overnight stay depending on your insurance and medical conditions.  The hospital stay for the other procedures averages two to three days, and may be longer for those with the open incision or complications. Patients undergoing the laparoscopic method usually have a two-day hospitalization.

When you return to your room after surgery, you will continue to be closely monitored by your nurses. Your family may visit with you then. Along with periodic monitoring of your vital signs (blood pressure, pulse, temperature, respirations), your nurses will encourage and assist you in performing deep breathing, coughing, leg movement exercises, and getting out of bed after surgery. These activities prevent complications.

Be certain to report any symptoms of nausea, anxiety, muscle spasms, increased pain or shortness of breath to your nurse.

To varying degrees, it is normal to experience fatigue, nausea and vomiting, sleeplessness, surgical pain, weakness and lightheadedness, loss of appetite, gas pain, flatus, loose stools, and emotional ups and downs in the early days and weeks after surgery.

What to Expect After Surgery

Immediately after surgery there is a moderate amount of discomfort. You will be given pain medicine by your nurse through your IV. We cannot remove all of the pain post-operatively but we will try to keep you as comfortable as possible. Tell your nurses and physician if you are having pain, particularly if it keeps you from moving, taking deep breaths, or feeling comfortable. Everyone is different, so keeping your nurses informed about how you feel will help them help you.

Activity/Exercises to Speed Up Your Recovery

With the help of your nurse, you should sit up and dangle your feet the night of surgery and stand at your bedside. If your surgery was in the early part of the day, you will be asked to get out of bed and walk. Starting the first day after surgery, you will be required to walk at least three to four times per day and to do your leg and breathing exercises hourly. Walking is extremely important for the prevention of blood clots.

Exercises that Speed Up Your Recovery

To enhance your recovery, your nurse will instruct you in coughing and deep breathing, turning in bed and exercising your feet and legs. You will be shown how to use an “incentive spirometer” to help you expand your lungs. Coughing and deep breathing is important so that you will loosen any secretions that may be in your throat or lungs and to help prevent pneumonia.  Deep breathing also increases circulation and promotes elimination of anesthesia.

The proper way to deep breathe

• Inhale as deeply as you can
• Hold breath for two seconds
• Exhale completely
• Repeat the above steps three times

and cough

• Inhale deeply
• Cough. The cough should come from the abdomen, not from your throat.
• Hold your pillow on your abdomen for support

Exercising your feet and legs is important for promoting good circulation.

The proper way to exercise your feet and legs is to follow these steps

• Push your toes of both feet towards the end of the bed (as in pressing down on a gas pedal)
• Pull your toes toward the head of your bed, then relax
• Circle each ankle to the right, then to the left
• Repeat the above steps three times

These exercises should be repeated at least once every hour after surgery, but it is also a good idea to practice these exercises before surgery to increase lung function and agility.

Diet

Gastric Bypass/Sleeve Gastrectomy/BPD

At the hospital, you will be served water on the first postoperative day, sugar-free clear liquids on day two, and protein drinks on day three as your new stomach pouch begins to heal. If you are doing well with no adverse signs, you will go home on day two and move on to protein drinks the next day at home. Most likely, you will not feel hungry the first week or so after surgery. This is normal with no reason for concern and may last a few weeks. However, it is very important to keep drinking water and to consume protein when at home to prevent dehydration and to promote healing.

Gastric Band

After surgery, you will have an esophagram performed in the radiology department. This is a set of x-rays taken after drinking liquid that will show the placement of the Band and how well fluid passes through your new Band. After these pictures are reviewed, you will start on liquids with protein drinks and be prepared for discharge home.

Urinary/Bowel Movements

Gastric Bypass patients will have a Foley catheter in your bladder to drain the urine after surgery. This will stay in for approximately 1 day. You may not have a bowel movement for a few days after surgery, but you should begin to pass gas in 2-3 days.

General Discharge Instructions

Your surgeon will determine your date of discharge based on your individual progress. Prior to discharge, specific dietary and activity instructions will be reviewed with you, along with precautions and situations when your surgeon should be notified. Discuss your going home concerns with your nurse or discharge coordinator. Remember no pills larger than an M&M. Check with your physician or pharmacist on whether or not the pills larger than an M&M can be cut or crushed. It is also extremely important that you stick to the post-operative diet. Do not advance your diet unless instructed by the physician, or dietitian. Your stomach needs time to heal; advancing your diet too quickly may cause serious, even fatal complications.

Please give some thought to your living environment. Are there many steps in your home? Is your bedroom upstairs? How accessible is your bathroom? Please tell the hospital staff about your living environment so they can prepare your going home with your specific needs in mind. Nonetheless, a rubber showerhead with a hose, long sponge stick and toilet lift are all useful items. Your hospital case coordinator, along with other members of your team, will work with you while you are in the hospital recovering from your surgery. She will assess your needs for care that may be required during your hospital stay, as well as assist you with your discharge from the hospital and arranging any home health care needs that may arise.

OTHER IMPORTANT INFORMATION

You can expect to see your surgeon every day. You will also be cared for by a team of resident physicians who will work closely with your surgeon and who will be monitoring your progress daily, not to mention nurses, dietitians and other therapists. The University Of Texas Center Medical School is a teaching institution and students of many types may be assisting in your care.