Before and after an operation

Surgical procedures and operations have become so commonplace that it is easy to forget that even relatively minor operations can be a major event in a person's life. Therefore anyone planning to have surgery should be prepared not just physically, but mentally and socially too (meaning domestic and work arrangements). You should only accept surgery if you consider that it is in your, or your child's, interests and that the benefits of the operation will outweigh the risks and disruption.

The term 'minor operation' usually means one that only involves a local anaesthetic (eg removal of a mole or sebaceous cyst from the skin), or one that only requires a quick general anaesthetic (eg removal of tonsils, insertion of grommets into the ears to treat glue ear or bunion operations).

A major operation is any operation requiring a longer anaesthetic or the opening up of the abdomen or chest.

Examples of major operations are:

• hip replacement
• coronary artery bypass grafting
• almost all organ transplants
• hemi-colectomy (removal of part of the large bowel).

Obviously there is a wide range of very different operations but some general principles apply to all, whether an operation is done as a routine (so-called 'elective' surgery) or whether it is an emergency.

Before surgery

Anaesthetic

Local anaesthetics: Local anaesthetics can be used in different ways to allow an operation to take place. For instance, they can be injected directly into the skin to numb an area. This technique is used for the removal of moles or to allow the insertion of a large needle to obtain a biopsy (small piece of tissue for analysis) from an organ inside the body (such as the liver). Local anaesthetic drops are used in a similar way to enable cataract removal without the need for a general anaesthetic.

Alternatively, local anaesthetic can be injected around certain nerves. This technique is most commonly used by dentists to numb part of the mouth but is also used by anaesthetists during some operations on the arm, hands or feet.

Finally, local anaesthetic can be injected into the fluid around the spinal cord (something called a 'spinal anaesthetic') or into a fatty layer around the spinal cord (an 'epidural'). Both of these result in complete numbness of the lower part or section of the body and allow the surgeon to perform certain major operations without the need for a general anaesthetic. Spinal and epidural anaesthetics are used for such operations as Caesarean section deliveries (allowing the mother to be awake during the birth of her child) and are also often preferable for major operations on the frail or elderly.

General anaesthetics: Under a general anaesthetic (GA), a patient is rendered unconscious in a carefully controlled way with the use of anaesthetic drugs given either into the veins and/or as an inhaled gas. This technique is suitable for major operations such as heart and chest surgery and most forms of abdominal surgery (because they require the abdominal muscles to be artificially paralysed for the duration of the operation). Since the stomach can empty involuntarily under GA, fasting is needed before a planned general anaesthetic. Eating and drinking immediately afterwards are not allowed either.

Pre-operative assessment

Pre-existing conditions need to be assessed before surgery to minimise their impact on the patient during and after the operation. Obvious examples are diabetes, heart disease, and thrombosis of the leg veins, but there are many others. This is why the anaesthetist (and/or a doctor from the surgical team) usually examines the patient a day or so before surgery, or sometimes the same day.

Depending on the nature of the operation and the general health of the patient, tests may need to be done, such as:

• chest x-ray for patients with chronic lung disease
• ECG (electrocardiogram) in patients over 65 years of age, or anyone with a history of heart trouble
• blood tests such as full blood count before any major operation.

Drugs and surgery

The surgeon and anaesthetist also need to know which drugs a patient is already on, for instance insulin or diabetic tablets, drugs for high blood pressure, anti-depressants and so on. This is because both prescribed drugs and those bought over-the-counter can affect the anaesthetic or the operation itself. In the case of patients who have needed to take steroid tablets over a length of time for conditions such as asthma or arthritis, a higher dose of steroid may be needed for several days to counteract the effects of surgery. A list of medicines, including any bought over the counter, should be brought into the hospital so that the hospital staff can check with you.

In some cases, women may be advised to discontinue the oral contraceptive pill to reduce the chance of developing a DVT (deep vein thrombosis, or clot in the leg) following surgery. The usual advice is for women on the combined oral contraceptive pill to stop taking it four weeks before any planned major surgery or any surgery to the legs. The pill can then be re-started on the first day of the period which starts at least two weeks after return to full mobility. Obviously it is important for other contraceptive measures to be used during this time.

Once in hospital, a sleeping pill may be on offer the night before a routine operation, even if the patient doesn't usually take any.

Social preparations

It's wise to think ahead about going home. On the simplest level, a relative may be needed to provide a lift from the hospital, while a neighbour might be able to shop for fresh groceries. Those who live alone may have to give some thought to security of their home, or to the welfare of any pets, especially if the stay in hospital turns out to be a bit longer than anticipated. It is advisable to stop smoking, as this will increase the chances of a trouble-free recovery.

Special preparations

Some planned operations demand specific preparations. The most obvious example is colon (bowel) surgery, which usually requires an empty bowel. This may involve several days on a low-residue (low fibre) diet, and then an enema or laxatives.

Consent for surgery

Faced with a consent form, patients sometimes joke about signing their life away, and leave most of their questions unasked. It is, however, much better to be well informed before having any surgery.

Although most people probably do not want to hear every single technical detail of the operation they are about to have, a patient must at least know enough to ensure that the consent he or she gives is truly 'informed'.

The most important issue about an operation is what the benefits are likely to be and what the possible risks are. Just as there is no such thing as a risk-free activity in normal life, it is also true that there is no such thing as a risk-free operation. The degree of risk will depend on a number of factors such as the difficulty of the operation, the health of the patient and whether or not it is a planned (elective) operation or is done as an emergency.

Useful questions to ask the surgeon include:

• what type of anaesthetic will be used - local or general?
• how long is the stay in hospital likely to be?
• if the operation involves any form of biopsy, how long will it be before the lab provides the result?
• is a blood transfusion anticipated?
• are there any special dietary requirements afterwards?
• what are the follow-up arrangements?
• will stitches need to be removed, and by whom - hospital staff or physician surgery?
• how long before it is safe to drive a car?
• how long is it necessary to stay off work?
• when can sex safely be resumed?
• how soon will it be safe to travel by train/air?

There may well be more questions to ask, depending on the exact operation to be done and each patient's circumstances.

After surgery

The recovery room

Often called simply 'recovery', the recovery room is a ward next to the operating theatre, which provides a high level of care by specially trained nurses while the patient is coming around after surgery. An anaesthetist is close at hand to give support if necessary. Because they may be feeling groggy, not all patients remember it well. After only a minor operation, time spent in the recovery room may be minimal, but it could be an hour or more after hip replacement, for example.

Once patients have recovered from the anaesthetic, they are returned to the ward or, after very large operations, they may be taken to ITU (intensive therapy unit) where an especially close watch is kept on all aspects of their recovery.

Pain relief

Many people who have just had surgery for the first time are surprised to have pain afterwards, as they felt nothing during the operation. New methods of operating, such as laparoscopic (keyhole) surgery, require much smaller cuts in the skin, so pain is less, but the reality is that a surgical wound is usually painful. Most people need some pain relief after surgery, especially for the first 72 hours.

When pain lasts much longer than this, or recurs after it had got better, it can be due to infection in the wound. Infections complicate a small number of operations, mostly those where the patient is debilitated and therefore has a low resistance, or where contamination has occurred, from bowel contents for instance.

Methods of delivering pain relief include:

• drugs that can be given as an injection such as pethidine, morphine and related drugs. The injection may be given either into the muscle of the thigh, into a vein, or sometimes into an epidural if this is already in place.
• drugs which can be given by mouth, like paracetamol and co-dydramol. These are milder painkillers, which are most suitable after minor operations, or after the first 48 hours following surgery.
• suppositories. Pain relief can also be given rectally in the form of suppositories; diclofenac is sometimes used in this way.

Nausea and vomiting

Nausea, retching and vomiting are nowadays much rarer after surgery than they once were, because anaesthetics have improved and also because surgical procedures are quicker than they used to be. Even so, these symptoms can occur shortly after an operation, either as a result of the surgery or the effect of drugs given during the anaesthetic.

These symptoms can be treated with anti-emetic medication, which is similar to travel-sickness tablets, but usually given by injection. When a patient is still retching or vomiting, eating and drinking are obviously out of the question for the time being, and fluid intake may have to be given intra-venous through a drip. The stomach may also have to be kept empty via a thin naso-gastric tube passed down through the nose.

Constipation

Many factors can cause constipation after surgery, including:

• bed-rest
• pain-killing drugs
• a low-fibre diet
• the operation itself.

Whatever the cause, the result can be uncomfortable, especially as straining is awkward in the presence of a recent surgical incision. Fortunately, suffering is not necessary and enemas are not always needed either, since there are now many gentler ways to produce a bowel movement. It is always a good idea to let the nurses know about whether the bowels have moved or not.

A less well known symptom in the early days after an abdominal operation is pain from trapped gas. This can cause a strange searing pain that travels from the middle of the belly slowly towards the back passage. It may be a little alarming at the time but is very short-lived. Any more persistent pain should of course be mentioned to the nursing staff or the doctor.

Retention of urine

Inability to pass urine can cause problems after an operation, particularly in men past middle age, when it is often due to a large prostate. However, retention also occurs in women. Simply being in bed, particularly in a strange place, can cause urinary retention and so can constipation.

Acute retention of urine is very uncomfortable because there is an intense desire to pass water, despite an inability to do so. If retention does not respond to simple measures (like being taken to the bathroom and running the taps) and constipation has been excluded, a urinary catheter may be needed as a temporary measure for, say, 24 to 48 hours. Men may rest assured that a little local anaesthetic jelly is first squirted into the tip of the penis to ease the discomfort of having the catheter inserted.

Deep vein thrombosis (DVT)

DVT is a potentially dangerous complication in which a clot forms in a vein, either in the leg or the pelvis. It can cause localised pain and swelling in the leg. More importantly, the clot, or thrombus, can sometimes become detached and travel up into the lungs, resulting in a pulmonary embolus, which can be fatal if it is large.

Reasons why DVT can occur include:

• immobility in bed, causing sluggish blood flow
• pressure on veins, especially from operations in the pelvic area (like hysterectomy)
• the fact that the blood itself becomes stickier and more liable to clot after an operation
• co-existing drug treatment, such as hormone replacement therapy (HRT) or the contraceptive pill
• close family history of a tendency to form blood clots.

Having said that, DVT is relatively rare because of measures to prevent it, such as:

• getting patients out of bed quickly after surgery
• giving anti-coagulant (blood thinning) drugs such as low-dose heparin or even aspirin tablets
• use of anti-embolic stockings which stimulate blood flow in the leg veins
• stopping the combined oral contraceptive pill in appropriate cases.

If despite all this a DVT develops, treatment with anti-coagulants can prevent the more serious complication of pulmonary embolism.

Confusion

Being in hospital can be disorientating, especially for the elderly, who may become confused after surgery.

There are many possible causes, such as:

• temporary lack of oxygen
• dehydration
• chest infection
• retention of urine
• pain
• side-effects of drugs
• other coincidental illnesses

It is disconcerting for families to have a relative who has suddenly become agitated or even aggressive following surgery, but it is usually a very temporary state of affairs. If there is anything they know about the patient (for instance his drinking habits) that might help the staff treat the episode of confusion, it is useful to share the information.

Emotions

With today's modern anaesthetics, people usually feel well and clear-headed when they come round from a general anaesthetic. All the same, patients may feel they are on an emotional roller-coaster after surgery. Even normally stoical souls can feel low or even weepy, often on the third or fourth day after a major operation. Although the exact cause isn't known, this is usually short-lived. Nurses sometimes maintain that one gets worse before one gets better, and that a patient's tears are a reliable sign of their imminent recovery.

It is also common to be a bit light-headed after a general anaesthetic, possibly because of blood pressure changes. This can last for a couple of weeks, and is often worse if one gets up quickly from a seated or lying position. One can faint if rising too quickly, so, unless symptoms are severe, the convalescent should just take the hint and try not to rush things.

Stitches

There are two main kinds of stitches:

• absorbable, which the body itself breaks down
• non-absorbable, which remain intact unless removed

Surgeons use absorbable material for much of the internal stitches, although non-absorbable material is used for holding bones or tendons together, and for hernia repairs.

The only stitches that most patients are concerned about are those in the skin. Sometimes these are absorbable, but usually they are not, and have to be removed a few days after the operation. Timing of removal varies according to the operation and to each surgeon's individual habits, but in general, abdominal stitches are taken out a week or more after surgery. Stitches on the face are usually removed much sooner. Either a doctor or a nurse may remove stitches, and the business is usually far quicker and less uncomfortable than most first-time patients imagine it will be.

Other forms of wound closure

In addition to stitches, other forms of wound closure material may be used if appropriate, e.g. surgical staples, glue and steri-strips.

Bedsores

Older patients may have memories of bedsores (more accurately known as pressure sores). These can occur after prolonged immobility in bed, but they are now rare because nursing care has improved dramatically, and because patients are becoming mobile much more quickly after surgery. In fact the whole experience of being a surgical patient has changed in the last few decades. The vast majority of people who have an operation nowadays have very few complications at all, and enjoy a much improved quality of life afterwards.

Last updated 8 August 2015