You may have had surgery in the past and are already familiar with some of the "routines" surrounding a trip to the operating room. Those who have never had a major surgical procedure may find the experience quite foreign and scary.
The treatment of gynecologic cancers almost always requires an initial surgical procedure. Sometimes the surgery is fairly simple and straightforward. At other times it is more complicated and requires a longer stay in the hospital and a longer recuperation period.
By the time you are first seen in our office your referring physician has probably already made a diagnosis by performing a biopsy or other tests. Knowing this, we will usually be able to discuss any planned surgery on the first visit you make to our office.
Sometimes we will need to get additional tests before we can determine what type of surgery will be required.
Scheduling surgery in the modern era of Managed Care is often a rather complicated procedure in itself! Once we inform the Surgery Scheduler that you will need a procedure she will have to perform a number of tasks before you can undergo your operation. Because of this, we will not be able to give you a surgery date for several days after your office appointment.
Most of the time your insurance company or medical group must first approve your surgery in writing before we can schedule a time for you to be admitted to the hospital and have your surgery. Our Surgery Scheduler will take care of this but, depending on your insurance, this can sometimes take several days to obtain. Since you are being referred to us for further care your insurance company will always approve your procedure. However, we are powerless to speed up the approval process.
If you have a type of insurance that does not limit your choice of hospitals then we have a much easier time finding available operating room time for your procedure. On the other hand, if your insurance limits you to 1 or 2 hospitals then we are also limited in finding an open time slot for your surgery in the immediate future.
You will always need to have some blood tests prior to your hospital admission. These will usually need to be performed within 7 days of your surgery (remember, we cannot schedule your surgery until your insurance company has given written approval so we can't tell you to get your blood tests performed until we know the date of your surgery). For most surgeries you will also need a chest x-ray and an EKG. Our Surgery Scheduler will tell you where to get all of your tests performed when she calls you to discuss your surgery date.
For most surgeries you will need to perform at least a minimal bowel prep. Sometimes only a mild laxative and a 1-day clear liquid diet is required. At the other extreme you may need a vigorous prep with very powerful laxatives and a 2-day clear liquid diet.
There are good reasons for this. Evacuating your colon of gas and fecal material makes abdominal and laparoscopic surgeries technically easier to perform. It also makes potential infectious complications of all surgeries less likely. We often need to remove portions of the colon for advanced gynecologic cancers (especially cancers of the ovary). If your colon has been adequately prepped then we can usually re-anastomose (sew together) the colon. If your colon is not adequately evacuated, however, then rather than re-anastomosing it we will need to give you a temporary colostomy. You can see how important a bowel prep is!
The anesthesiologist is, arguably, the most important person in the operating room. After all he/she is going to keep you pain-free during your procedure. All of the anesthesiologists we work with are top-notch physicians. We wouldn't have it any other way. I have a tremendous amount of confidence in the anesthesiologists with whom I work. In fact, when members of my own family have had surgery in the past I have not even bothered to find out who was assigned to the case until the day of surgery! I leave decisions about the type of anesthesia to be used during your surgery to the anesthesiologist. He/she will discuss the options with you prior to your surgery.
Coming to the Hospital
You will need to come to the hospital several hours prior to your planned procedure. Our Surgery Scheduler will tell you approximately what time you should present yourself. In the pre-operative area Nurses will check all of your laboratory studies and make sure that all of the proper paperwork is completed. They will also start an intravenous line in one of the veins of your arm. Your family and friends can be with you during all of this.
Just prior to your surgery the anesthesiologist will again talk with you and your family and answer any questions you may have. He/she will also probably examine your mouth and neck at that time. I will also see you at this time for any last minute questions.
You will be given an intravenous sedative prior to being taken into the operating room. One of the more common pre-operative medications given, Versed, has a powerful amnesic effect. Even though you are lucid and "awake" after receiving this drug you will probably have no memory of any events following its administration.
The Surgical Waiting Room
If you have family/friends who wish to be informed of the outcome of your procedure then it is best that they go to the Surgical Waiting Room while you are having your procedure. I would really like to speak to your family/friends after your surgery so that they can be assured that you are fine and the procedure went well. Since we can never really know just how long a surgical procedure will take it is best that your family/friends plant themselves in the Surgical Waiting Room and not wander off to the cafeteria, etc. If I cannot find your family/friends in the Waiting Room after your surgery then I will assume that they have left the hospital and do not want to discuss your outcome with me.
Although we cannot take away all of your pain after surgery, we try very hard to minimize your discomfort. We have many methods to treat pain after surgery nowadays including;
- Long acting intrathecal narcotics. These are administered by the anesthesiologist via a "spinal tap" just prior to your surgery. Surgical pain is almost eliminated for about 24 hours after the surgery.
- Epidural narcotic infusion. This is also initiated by the anesthesiologist by placing a small tube (catheter) into a space around your spinal cord. Narcotic medication is then infused continuously for several days after surgery.
- Patient Controlled Analgesia (PCA). Pain medication is given intravenously via a computerized pump after surgery. Typically a minute amount of narcotic is given continuously and you also have the option of giving yourself an additional boost of medication by pushing a button on a cord attached to the pump. The amount of medication you are allowed is rigidly controlled by the computerized pump so that you cannot ever overdose yourself. Almost all of our patients will have a PCA postoperatively.
- Incisional Analgesia. The newest form of pain control consists of local anesthetic agents (eg Xylocaine, Lidocaine, etc) infused in minute quantities directly into the area of the incision. This is done by an ingenious, small pump connected to tiny catheters placed in the subcutaneous fat of the abdominal wall at the time of surgery.
We rarely need to transfuse blood during or after surgical procedures. In Oncology specialties it is more common for patients getting chemotherapy to require blood transfusion occasionally during their treatments.
The risk of getting a transmissible disease from blood products (eg, HIV, hepatitis) is quite low (i.e. 1:100,000 risk). We think of blood products in the same way we would think of any drug. They should only be given if absolutely necessary and the benefit greatly outweighs any risk. When I or one of my partners order a blood transfusion for you it is because it really is absolutely necessary for your immediate health and safety.
We can usually predict when you will need a blood transfusion with enough time for you to designate a blood donor such as a spouse or relative. Interestingly, it turns out that the risk of contracting a transmissible disease from designated donor blood is equivalent to that of random donor units!
After abdominal surgery your gastrointestinal tract "goes to sleep" for several days. If you were to eat food immediately after surgery it would not travel through your stomach and intestines normally. This would put you at risk of vomiting. Not only is this uncomfortable after surgery but it can also be dangerous and might require us to place a nasogastric tube (a tube that travels though you nose to your stomach)!
To prevent complications of early feeding we will advance your diet slowly after surgery. If you have had a rather simple abdominal procedure we might start you on a clear liquid diet the day after surgery. If your surgery was a little more complicated we may not initiate a clear liquid diet for several days after surgery. If it looks like it will be more than a few days after surgery before we can safely initiate a diet then you may need to be fed intravenously. We can actually provide a "perfect" diet intravenously using a very special material called "Total Parenteral Nutrition" (TPN). Believe it or not, our bodies don't really need to have a lot of food post-operatively. Nevertheless, we will let you eat as soon as it is safe to do so (we're not trying to torture you!). If you have had either a trans-vaginal surgery or a laparoscopic procedure you can tolerate feedings immediately. Even so, until you have an appetite it is best to avoid eating a lot of solid foods - drink a lot of fluid instead.
If you have had a laparoscopic surgery you will have tiny incisions just under your umbilicus, just above your pubic bone and in the right lower area of your abdomen. If you have had a major abdominal surgery you will have either a “bikini” (transverse), or an up-and-down (midline) incision.
The skin of laparoscopic incisions and some transverse incisions can often be held together with a dissolvable suture in the skin and/or a special type of “skin glue”. The skin of many transverse and most vertical incisions must be held together with little metal staples that are removed 5 – 10 days after your surgery. It “picks” a little when the staples are removed but the skin heals beautifully.
The strongest and most important layer of the abdominal wall is called the fascia. When cut transversely (as in a “bikini” incision) this layer is under very little tension when it is re-approximated and tends to heal very nicely without any special consideration. When the fascia is cut in an “up-and-down” fashion it is under sometimes considerable tension when it is re-approximated at the end of your surgery. This places you at risk of developing a hernia in the incision site.
If you have an “up-and-down” incision the risk of hernia formation is decreased if you:
1.) Avoid any activity that causes you to “bear down” (e.g., chronic constipation, chronic coughing, repeatedly lifting or moving heavy objects, etc). Use stool softeners (Metamucil, Citrucel, Colace) liberally for 3 months postoperatively. If you develop a cough or bronchitis then call us so that we can prescribe an antibiotic and/or cough suppressant. Avoid heavy lifting or physically demanding work for at least 3 months after surgery.
2.) Wear an abdominal binder during the day for 3 months after surgery. The binder should fit “snuggly” but not tightly. You do not need to wear the binder when you sleep. You can find binders that fit a female torso at http://www.compressiongarments.net)
All skin incisions will heal with some degree of scarring. This is normal and expected. You can decrease the amount of scarring to some degree by applying either Mederma (a lotion available without a prescription in most pharmacies) or special wound covering strips available without a prescription at most pharmacies (eg BandAid Scar Healing strips http://www.bandaid.com/scar_healing.shtml, or ScarGuard http://www.scarguard.com ).
When you go home from the hospital there are very few special precautions. There is little you can do to speed up or slow down your healing.
If you have had an abdominal procedure I ask that you not drive a car for at least 2 weeks. If you have had a vaginal or laparoscopic procedure then it’s best not to drive for about 1 week.
You can otherwise do just about anything within reason. That means you can go up and down stairs, pick things up, bathe, shower, sit in a Jacuzzi (yes, you can get your incision wet), eat anything you want, etc. You can resume your regular exercise routine if you pay attention to what your body is telling you. If you are doing some type of exercise that hurts your incision then, obviously, stop what you are doing.
If you are tired then lie down and rest. However, you should “push it a little” – don’t lie around in bed all day. If your body needs food then you will feel hungry. Don’t eat food if you are not hungry, you will only make yourself sick. You do, however, need to drink plenty of fluid. Sport drinks like Gatorade are actually very similar in composition to the intravenous fluids we give you in the hospital. These products are great for you after surgery. I recommend that you always keep a cold glass of Gatorade nearby and sip on it continuously. You’ll know that you are getting enough fluid if you are urinating frequently throughout the day.
Depending on the type of surgery you have had you will need to forego any sexual relations for a period of time. If you have had a minor laparoscopic procedure, for instance, you’ll have to abstain for about a week. If you have had a hysterectomy or other major vaginal or vulvar surgery you’ll have to wait for 2 – 4 weeks.
It is natural to have various aches, pains, pulls, twangs, gas, etc throughout your abdomen, lower back thighs and shoulders for up to 6 months after abdominal surgery. Our bodies just do not like it when someone starts re-arranging things in there! As long as any aches are not associated with nausea and vomiting or with a fever over 101 degrees then it’s nothing to worry about.
Your incision will be tender and even slightly red for a week or so after surgery. This is especially true if you have been sent home with staples holding the skin edges together. Contact us if you see the incision getting redder or more tender over time. If you have had a hysterectomy or any type of vaginal surgery you can expect to have a vaginal discharge for up to 6 weeks following surgery. Any vaginal incision takes several weeks to heal completely. Until complete healing occurs you will experience some type of vaginal discharge. The discharge can range from a small amount of clear, “sticky” material to what might seem like a menstrual flow.
If you had anything other than a very minor outpatient type of surgery you will need some help at home after discharge. Remember you are going to be sore and might need assistance getting to the restroom, for instance (especially in the middle of the night). Everyone heals up at different rates but I would suggest that someone be nearby 24 hours a day for at least 2 days after you go home. You will be sent home with a strong type of oral pain medication. All good pain medications can cause a low-grade type of nausea, stomach upset, and constipation.
It’s best to switch to an over-the-counter drug like Tylenol or Advil (no Aspirin) as soon as possible. You may have been able to go home before we have a final Pathology report from your surgery. I will call you with these results as soon as I have the final hard copy from the laboratory. Please do not call the office looking for results. If I have not called you yet then the results are not available.