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Caring for Yourself After Surgery

Dr. Parker’s Discharge Instructions and Suggestions after Laparoscopic Surgery

Disclaimer: it is important for you to follow your own doctor’s instructions.

ACTIVITY AFTER SURGERY:

  • No strenuous exercise or intercourse for 4-6 weeks
  • You may start walking for exercise on day 1
    • Walking is the best activity following surgery.  You can walk up and down stairs, outside, and on a treadmill.  Walking will keep your circulation going and build back your stamina.
  • Fatigue – fatigue is extremely common after surgery and may last many weeks.
  • Iron – to help build back any blood lost during surgery. Either Fergon or SlowFe – 1-3 times a day along with 1,000mg of vitamin C (helps with the absorption of iron)
  • You may start driving when you are no longer taking narcotic pain medication and you   feel it is SAFE for you to drive.
  • Showers only (no baths) for the first 2 weeks.

PAIN/DISCOMFORT MANAGEMENT

  • For pain, we will prescribe either Norco 5/320mg or Percocet 5/325mg for you to take once you get home.
    • Days 2-3 may be worst, pain-wise
    • Some cramping and shooting pains are normal, even in areas away from the incisions
    • Do not drive under the influence of narcotic pain medication
  • Lowering, raising and turning yourself will hurt (try using your arms instead of abs)
  • Urination may burn/pinch initially, but will get easier (avoiding caffeine). Taking D-Mannose helps.
  • Shoulder Pain – In order to see the pelvic organs during laparoscopic surgery, we need to put carbon dioxide gas (CO2) into the abdomen which pushes the bowel out of the way.  If the CO2 is left in the abdomen, it can irritate the nerve under the diaphragms.  This nerve runs close to the nerves for your shoulder and the gas will cause shoulder and back pain.  The pain can be sharp and can last for a day or two.  Sometimes changing position can help, but over time the pain will go away.

INCISIONS

Depending on the type of laparoscopic surgery you have, you will have either 2, 3 or 4 small incisions.  Usually the first 1/2 inch incision is made in the navel.  For a laparoscopic myomectomy, a 1/3 inch incision is made a few inches to the left of the navel and another incision is made a few inches to the right side of the navel.  The last incision is about 3/4 inch and is placed on the right side above the hip bone.  For larger fibroids, the incisions will be higher.  For laparoscopic hysterectomy the right side smaller incision is not necessary.

At the end of the surgery, I inject local anesthesia into the incisions which provides a few hours of some pain relief.  You will likely have some pain in the recovery room and then nurses will give you pain medication as needed. When the local anesthesia wears off, you will have some incisional pain and, during your pre-op visit to the office, we will give you a prescription for pain medication to take at home.  The larger incision on the right side tends to be uncomfortable for a few weeks since it is larger, gets more sutures and is close to a nerve.

  • It is OK to shower with steri-strips (do not scrub the wounds). You can remove the steri-strips after a week. After the steri-strips are removed, I suggest you buy Scar Away at the drug store. Scar away is a silicon bandage (like a large band-aid) that you can cut into small strips and put over the incisions for as many hours a day as you can.  Over time, the Scar Away thins and lightens the incisions so that they heal more nicely.
  • Bruising: bruising around the incision(s) is very common, even beyond the surgery area, for a few weeks after surgery.  Cold packs can keep the incision swelling down and the bruising will go away by itself.
  • Lumpy Incisions – the sutures dissolve by themselves and are replaced by collagen scar tissue.  Initially, the collagen is thick and may be bumpy.  Over the next few months the initial collagen is replaced by a softer type of collagen and the bumps will go away.

DIET AND BOWEL ISSUES

  • No dietary restrictions
    • Avoid foods that cause gas such as broccoli, cauliflower and brussel sprouts
  • No alcohol if taking narcotic pain medications
  • Chewing gum helps with bowel function
  • Walking helps bowel function
  • Constipation is unusual after laparoscopic surgery.  But, if you have constipation you may take Metamucil or Colace as needed (over-the-cunter).
  • Expect some gas discomfort/pain.  Gas pain can be relieved by walking, taking medication (Mylicon, Gas-X) and chewing gum.  Bending your legs while lying on your back may also help.
  • Bloating (“swelly belly”) is normal for up to 2-4 weeks and will go away by itself. Surgery irritates and slows down the intestines and they retain more gas and stool.

PERIODS

  • Some bleeding and/or clumpy discharge is normal for a few weeks.
  • Periods won’t be normal again for 3-4 cycles – they may be heavy, light, long, short – anything can happen while you are healing.

 CALL US AT 310-451-8144 FOR:

Fever over 100.4 degrees F, bad pain unrelieved by pain medications, heavy bleeding, vomiting, dizziness, pus-like drainage from the wound or other concerns.

You can read other women’s post-op experiences at: http://geekwithfibroids.wordpress.com

 SUGGESTED TO WEAR/BRING TO THE HOSPITAL

  • Comfortable slip-on flat shoes
  • Pants or skirt with elastic or drawstring waistband
  • Pillow for the car ride home (leave in car to put between your stomach and seat belt)
  • Lip balm (your mouth may be parched)
  • Your ID
  • Advance directives (optional)

 

BEFORE SURGERY –  SUGGESTED SHOPPING LIST

  • Throat lozenges: Sometimes the tube placed down your windpipe (trachea) can cause irritation which can feel like a sore throat.   At times, this irritation can lead to a not very pleasant feeling cough.  Lozenges can help soothe your throat and also help minimize the coughing.
  • Stool softener: Many types are available:  Smooth Move tea, Colace, Peri-Colace (stool softener and mild laxative together).  High-fiber foods.
  • Anti-gas pains: Mylicon, Maalox, Gas-X or peppermint tea
  • Three days of groceries/easy-prep foods, since you won’t feel like cooking. Consider broth/soup, fruits + veggies (avoid gassy ones like broccoli, cauliflower and Brussels sprouts), rice, crackers, juice, yogurt.

 

BEFORE MYOMECTOMY

We ask women to insert 2 tablets (Cytotec) vaginally about  2 hours before surgery. Cytotec has been shown to decrease blood loss during myomectomy surgery. However, it can also cause cramping, vaginal bleeding and, sometimes nausea. If you have any of these symptoms, they are normal (and we apologize), but the medication does help decrease surgical blood loss.

Dr. Parker’s Discharge Instructions and Suggestions after Open Abdominal Surgery

Disclaimer: it is important for you to follow your own doctor’s instructions.

HOSPITAL RECOVERY

In the hospital, the nurses will remove the bladder catheter a few hours after surgery and they will ask you to sit in a chair and walk to the bathroom the night of surgery.  You will have the ON-Q pain pump (see below), but if you need other pain medication, ask the nurses and they will give it to you.  By the morning after surgery, you will be eating regular food and you will be able to walk in the hall.  Recent studies of this “enhanced surgical recovery” show that a quicker return to normal activities and diet was associated with faster patient recovery and a shorter hospital stay.

ACTIVITY AFTER SURGERY:

  • No strenuous exercise or intercourse for 4-6 weeks
  • You may start walking for exercise on day 1
    • Walking is the best activity following surgery.  You can walk up and down stairs, outside, and on a treadmill.  Walking will keep your circulation going and build back your stamina.
  • Fatigue: fatigue is extremely common after surgery and may last many weeks.
  • Iron – to help build back any blood lost during surgery. Either Fergon or SlowFe – 1-3 times a day along with 1,000mg of vitamin C (helps with the absorption of iron)
  • You may start driving when you are no longer taking narcotic pain medication and you feel it is SAFE for you to drive.
  • Showers only (no baths) for the first 2 weeks

PAIN/DISCOMFORT MANAGEMENT

  • For pain, we will prescribe either Norco 5/320mg or Percocet 5/325mg for you to take once you get home.
  • Days 2-3 may be worst, pain-wise
  • Some cramping and shooting pains are normal, even in areas away from the incisions
  • Do not drive under the influence of narcotic pain medication
  • “ON-Q” pain pump: I use an innovative device to relive post-operative pain called the ON-Q pain pump. As we are closing the incision, two tiny plastic tubes are inserted underneath the incision. The tubes are connected to a tennis ball sized pump that holds a solution of local anesthesia.  The pump slowly and automatically pushes the local anesthetic into the incision – exactly where you need it You don’t need to touch it). The ON-Q pump greatly reduces the need for injected narcotic pain medication doesn’t cause the grogginess that often accompanies narcotics.  The device lasts 3-4 days and then is easily, and absolutely painlessly, removed in the office when the suture is removed.
  • Lowering, raising and turning yourself will hurt (try using your arms instead of abs)
  • Urination may burn/pinch initially, but will get easier (avoiding caffeine). Taking D-Mannose helps.

PERIODS

  • Some bleeding and/or clumpy discharge is normal for a few weeks.
  • Periods won’t be normal again for 3-4 cycles

CALL US AT 310-451-8144 FOR:

Fever over 100.4 degrees F, bad pain unrelieved by pain medications, heavy bleeding, vomiting, dizziness, pus-like drainage from the wound or other concerns.

 DIET AND BOWEL ISSUES

  • No dietary restrictions
    • Avoid foods that cause gas such as broccoli, cauliflower and brussel sprouts
  • No alcohol if taking narcotic pain medications
  • Chewing gum helps with bowel function
  • Walking helps bowel function
  • Constipation is normal for a few days after abdominal surgery.  You may take Metamucil (fiber) or colace as needed.
  • Expect some gas discomfort/pain.  Gas pain can be relieved by walking, taking medication (Mylicon, Gas-X) and chewing gum.  Bending your legs while lying on your back may also help.
  • Bloating (“swelly belly”) is normal for up to 6-8 weeks and will go away by itself.  Surgery irritates and slows down the intestines and they retain more gas and stool. Some women find that an abdominal binder reduces pressure on the incision and helps them feel more support.  You can buy an abdominal binder at a surgical supply store or pharmacy.

INCISION HEALING

  • Skin incision – I close the skin incision with a suture technique that I learned from a plastic surgeon.  I use one continuous suture that is removed about 5-7 days after surgery, so that no suture material is left under the skin.  This technique decreases the chance of a thick scar.  I then place steri-strips (like band-aids) across the incision to take the tension off of the skin, which also decreases the risk of a thick scar.  The suture is quickly and painlessly removed in the office by our nurses and, if needed, the steri-strips are replaced.  There are many layers of suture below the skin holding the incision together and these sutures dissolve a few months after surgery.
  • It is OK to shower with steri-strips (do not scrub the wound). You can remove the steri-strips after a week. After the steri-strips are removed, I suggest you buy Scar Away at the drug store.  Scar away is a silicon bandage (like a large band-aid) and you keep it on the incision for as many hours a day as you can.  Over time, the scar away thins and lightens the incision so that it heals more nicely.
  • Bruising: bruising around the incision(s) is very common, even beyond the surgery area, for a few weeks after surgery.  Cold packs can keep the incision swelling down and the bruising will go away by itself.
  • Incision “Shelf”: the first scar tissue that forms in the incision is made up of a thick, stiff collagen, which pulls the scar inward and leads to a “shelf” over the incision.  Over the next 3-6 months, the first collagen is slowly replaced by a more elastic collagen and the incision becomes flat with the rest of the skin.
  • Numbness: when we make the initial incisions to get to the uterus, we stretch, tear or even cut the very small nerves that go to the skin on the abdomen.  As a result, it is very common to have numbness, tingling, burning or itching above the incision for a few months after surgery.

APPOINTMENTS AFTER SURGERY:

  • Suture and ON-Q pain pump removal 5-7 days after surgery – with Dr. Parker’s nurse or nurse practitioner
  • Appointment with Dr. Parker 2 weeks after surgery
  • Appointment with Dr. Parker 6 weeks after surgery

You can read other women’s post-op experiences at:  http://geekwithfibroids.wordpress.com

SUGGESTED TO WEAR/BRING TO THE HOSPITAL

  • Comfortable slip-on flat shoes
  • Pants or skirt with elastic or drawstring waistband
  • Pillow for the car ride home (leave in car to put between your stomach and seat belt)
  • Lip balm (your mouth may be parched)
  • Your ID
  • Advance directives (optional)

BEFORE SURGERY –  SUGGESTED SHOPPING LIST

  • Throat lozenges: Sometimes the tube placed down your windpipe (trachea) can cause irritation which can feel like a sore throat.   At times, this irritation can lead to a not very pleasant feeling cough.  Lozenges can help soothe your throat and also help minimize the coughing.
  • Stool softener: Many types are available:  Smooth Move tea, Colace, Peri-Colace (stool softener and mild laxative together).  High-fiber foods.
  • Anti-gas pains: Mylicon, Maalox, Gas-X or peppermint tea
  • Three days of groceries/easy-prep foods, since you won’t feel like cooking. Consider broth/soup, fruits + veggies (avoid gassy ones like broccoli, cauliflower and Brussels sprouts), rice, crackers, juice, yogurt.

BEFORE MYOMECTOMY

We ask women to insert 2 tablets (Cytotec) vaginally about  2 hours before surgery. Cytotec has been shown to decrease blood loss during myomectomy surgery.  However, it can also cause cramping, vaginal bleeding and, sometimes nausea.   If you have any of these symptoms, they are normal (and we apologize), but the medication does help decrease surgical blood loss.

New Research on the Myths Regarding Instructions Doctors Give Following Surgery

A recent study from National Institutes of Health recommends that doctors change many of the current restrictions on activities following gynecologic surgery. After reviewing information from medical journals, medical textbooks in obstetrics, gynecology, and general surgery, the American College of Obstetricians and Gynecologists Practice Bulletins and Committee Opinions and clinical guidelines of Royal College of Obstetricians and Gynecologists of the United Kingdom, they found that the available studies do not support many of the recommendations currently provided by doctors. Resumption of usual activities after gynecologic surgery helps integrate women back into normal life and, although more study is needed, they suggested the following after abdominal surgery (restrictions are less after laparoscopic surgery):

Resumption of Normal Activity: Prolonged bed rest increases the risk of pneumonia and blood clots in the legs. A quick return to normal activity after gynecologic surgery should decrease the likelihood of these problems. For most women, normal activity includes walking, lifting, and climbing stairs. Many of the previous restrictions were intended to avoid straining the abdominal incision in a way that might cause it to open. But, as seen below, these fears are not justified.

Lifting: Patients have usually been instructed to not lift more than 10 pounds. However, normal events like forceful coughing (which we often encourage you to do) , or getting up from a lying down position (which you have to do to get out of bed every morning) place more stress on the incision than lifting. In fact, the force needed to tear open a surgical incision is much greater than the force generated by any kind of daily activity.

Poor nutrition, infection, obesity, anemia, and diabetes, as well as the type of suture material and the surgeon’s technique are more likely causes of the incision opening after surgery.

Climbing Stairs: Climbing stairs is a common and normal activity. There is no evidence that climbing stairs increases the risk of the incision opening.

Bathing and Swimming: Baths have usually not been permitted for 2 to 6 weeks after surgery in order to prevent wound infection. However, if the incision is closed and not already infected, there is no evidence that a tub bath is harmful once the bandage has been removed.

Driving a Car: The concerns have been that the physical activity associated with driving might cause the wound to open or that post-operative pain might cause you to hesitate to step on the brakes quickly in an emergency. However, there is no evidence that these things are true. It is a good idea to first try the pedals and hand controls in a stationery car. If this feels comfortable, then take the car for a short ride accompanied by another adult who could drive the car if you feel unable to continue driving.

More important is the possibility that narcotic pain medication may cause drowsiness or slow your reflexes while driving. Therefore, you should not drive until you no longer need narcotic pain medication.

Sex Following Hysterectomy: Sex can probably be initiated once you are comfortable and both partners are ready. If your cervix has been removed with the uterus (total hysterectomy), there is a small risk of infection around the sutures left in the vagina and a small risk of these sutures coming undone during intercourse. If you are menopausal, had prior pelvic radiation therapy, or have diabetes your risk is higher.

The cervix is a major source of normal lubrication, so if your cervix has been removed it is best to use vaginal lubricants during sex and try sexual positions with the woman on top so penetration can be controlled. This puts less pressure on the sutures at the top of the vagina.

If your cervix was left in place (supracervical hysterectomy) the risk of infection is even less and there are no sutures at the top of the vagina to worry about coming apart.

Returning to Work After Gynecologic Surgery: Advice on when to return to work varies greatly. In the United Kingdom, a survey found that doctors recommended returning to work anywhere from 1 to 10 weeks after surgery. It appears that a gradual return to work is better than an abrupt return to full-time work.

Recovery at Home After Major Gynecologic Surgery

Authors: Evenson M, Payne D, Nygaard I.

Source: Obstetrics and Gynecology, 2012;119:780-4

Study from: University of Utah School of Medicine

Problem: Women’s recovery and pain control during the first 6 weeks following gynecologic surgery has not been well studied.

Study: Women having either abdominal or vaginal surgery were asked to determine their pain and pain medication use after surgery.

Results:  80 women had vaginal surgery; some women had a hysterectomy and others had bladder repair surgery. 47 women had abdominal surgery; some women had a hysterectomy and others had removal of fibroids (myomectomy) or ovarian cysts.

On recovery day 3, inadequate pain control was reported by about 50% of women in both groups and at the end of one week 25% of women had inadequate pain control.  By day 14, most women who had vaginal surgery had minimal pain, but 20% of women still had pain after abdominal surgery.  Two weeks after discharge, narcotic pain medication was still being used by 10% of women after vaginal surgery and 32% of women after abdominal surgery.  By 6 weeks, half of the women in each group felt recovered and two-thirds felt “back to normal.”

Authors’ Conclusions: Pain control after hospital discharge is inadequate for many women after both vaginal and abdominal surgery. The time to full recovery is longer than 6 weeks for half of women.

Dr. Parker’s Comments: Recovery from surgery varies from woman to woman, but it usually takes a bit longer than either the doctor or patient hopes will be the case.  In the past 10 years, doctors have been better educated about helping patients manage pain, but some doctors still discourage use of pain medicines and many patients stop using pain medicine before they should.   Laparoscopic surgery has been proven to cause less pain and have a faster recovery than abdominal or vaginal surgery. But, even following laparoscopic surgery, patients often try to return to normal activity faster than they should.

I always tell patients that there is no advantage to being a martyr and that they will sleep better and feel better if they take some pain medication for the first few weeks after surgery. Also, patients are not aware of the level of fatigue that they will feel after surgery. And, the fatigue can last for weeks after the pain has gone away.  Fatigue is due to a number of things: the effects of anesthesia and narcotic pain medication; the stress of surgery on the body; tissue injury and release of proteins (cytokines) into the bloodstream that are sedating (nature’s way to force you to rest); and, injured tissues need for energy to heal, leaving little reserve for the rest of your body.

So, some form of pain medication allows you to rest more and sleep better.  Also understand that recovery and return of energy may take longer than you wish.

These new recommendations need to be fully tested by scientific study, but since this is unlikely to happen soon (or ever), it is best to discuss the new recommendations with your doctor.

By William H. Parker, MD
Clinical Professor, Obstetrics and Gynecology, UCLA School of Medicine
Director of Minimally Invasive Gynecologic Surgery, UCLA Medical Center, Santa Monica

Page last updated: February 2, 2015

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Disclaimer: The ideas, procedures and suggestions contained on this web site are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision.

Fibroid Doctor William H. Parker

Dr. William H. Parker is a board-certified Fellow in the American College of Obstetricians and Gynecologists. Dr. Parker is an internationally recognized expert in fibroid surgery and research. Based in Los Angeles, California, he is considered one of the best fibroid surgeons for abdominal and laparoscopic myomectomy in the United States and abroad. He has been chosen for Best Doctors in America and Top Doctors every year beginning in the late 90's.

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