Types of Craniotomy

A craniotomy can be done in different ways depending on the type of surgery that follows it. The types of craniotomies are:

A traditional craniotomy where the bone flap or part of the skull is removed and put back in place once the surgery is complete.

A burr hole where only a small hole is made in the skull instead of removing a portion of the skull.

In stereotaxy the inside of the brain is viewed using a computer.

Craniotomy is done under general anesthesia. However, an awake craniotomy, is done while the patient is awake—that is using only local anesthesia.

Reasons for Craniotomy

A craniotomy can be done for following:

• Inspection the brain for visible problems.
• Serious brain injury or head trauma.
• Removal of blood clot or hematoma from the brain.
• Biopsy – to take tissue samples from the brain to test for cancer.
• To draining an abscess of the brain.
• Relieving pressure against the skull from swelling of the brain.
• Controlling hemorrhage from a leaking blood vessel — cerebral aneurysm.
• Repairing of blood vessel problems.
• Brain tumor or cancer.
• Nerve disorders.
• Infections in the brain.

Preparation

To prepare for the surgery, tests are ordered by the doctor several days before the procedure. These tests include blood tests, chest x-ray, electrocardiogram as well as a brain scan b y MRI, CT, or PET.

The patient should not take anti-inflammatory medicines or blood thinners, for at least one week before the procedure. The doctor may prescribe medications to take prior to surgery to remove anxiety and/or prevent procedure swelling, infection or seizures after surgery.

The patient should stop smoking, chewing tobacco, and drinking alcohol for 1-2 weeks before the surgery since these are known to cause complications during and after surgery and thereby slowing down the healing process.

The patient should not eat or drink anything for at least 8 – 12 hours prior to the procedure.

Just before the procedure, the patient’s head is shaved over the area where the craniotomy will be done. The scalp is usually shaved in the shape of a small horse-shoe.

As a preparation for the procedure, general anesthesia is administered through an IV placed in the arm, before the surgery to put the patient to sleep completely. However, if the patient is undergoing an awake craniotomy, general anesthesia is given, but the patient will be awake for a part of the procedure. In case of stereotaxy, local anesthesia is administered only in the area of operation.

The Procedure

Once anesthesia takes effect and the patient is asleep, the head is help in a fixed position using a 3-pin skull fixation device. Next, a drain is placed in the lower back to drain off the cerebrospinal fluid secreted in the brain and passed through the spinal column. Removing the spinal fluid helps relieve pressure from the brain during surgery. The scalp is then prepped with an antiseptic and an incision made on the skin. The incision may be made either around the occipital bone at the nape of the neck or a curved incision above the ear and eye. Care is taken to avoid the hairline; however, if the surgeon thinks it is needed he may shave a part of the head and cut there.

Once the incision is made, the skin, muscles and tissues of the scalp are then folded back and the skull is exposed. Next, small holes are drilled in the skull using a high speed drill and a bone saw to cut out a flap through the holes. This bone flap is then removed to expose the brain tissues at the area the surgeon will do surgery or examination.

After surgery, the bone flap is put back in place and held with soft wires, plates and screws. The surgeon may choose to place a drain under the skin to remove blood and fluid from the site of the surgery. The drain may stay in place for 1-2 days. The skin and muscles are then sewn together. Finally, a bandage or dressing is put over the incision.

The complete procedure, from anesthesia to the wearing off of the anesthesia post-surgery, takes about 4-6 hours.

After Craniotomy

After the surgery, the patient is taken to the recovery room and watched closely. The vital signs (that is, temperature, blood pressure, heart rate, and breathing) are monitored. The breathing tubes and catheters are usually left in place and a drip may be put into a vein to give fluids. AFter the patient wakes up, the patient is then transferred to the ICU (intensive care unit) for further neurological observation. The patient is asked to do simple commands like move their hands, legs, fingers, toes to check for complications from surgery.

Nausea and headaches are common after a craniotomy. Medicines can be given to control these along with seizures and swelling in the brain following surgery.

If everything is going as expected, the patient is transferred to a regular hospital room, where the patient may stay for 3-14 days depending on the type of brain surgery and if there are any complications.

The patient is discharged with instructions to follow at home and to make an appointment to see the doctor in 7-10 days to have stitches or staple removed.

Risks and Complications

Complications from a craniotomy are usually of 3 types:

• those normally associated with any kind of surgery
• those related to the craniotomy procedure
• those related to the surgery done on brain and nerves after the craniotomy

The common risks associated with any type of surgery include bleeding; infections; blood clots; risks related to anesthesia like lightheadedness, low blood pressure, etc.

Complications associated with the craniotomy include retention of fluid and later swelling of the brain.

Depending on the type of surgery done on the brain, complications can be unintentional damage to the brain tissues and nerves causing loss of brain functions (that is, problem with memory, thinking, speech or behavior) or even causing disabilities like deafness, blindness, double vision, loss of sense of smell, numbness, paralysis, problems with balance, seizures, or bowel and bladder problems. The risk of specific complications depends on which area of the brain is affected by the surgery.

Postsurgery Home Care

In order to speed up your recovery, the patient should get plenty of rest and eat a healthy diet. In addition, take all medications exactly as prescribed by the doctor for pain, swelling and/or seizures. Some pain medicines can cause constipation, which can be controlled by drinking plenty of water and eating food high in fiber.

Care should be taken of incision site. You can take a shower 3-4 days after surgery but don’t get the incision wet—wear a shower cap. The incision should be kept dry until the sutures are taken out and the skin heals. The sutures or staples are usually removed 7-10 days after surgery.

Depending on the type of the surgery, physical therapy, occupational therapy and/or speech therapy may be ordered. Therapy can help improve speech and strength and the ability to do activities of daily living. However, it is very common for the patient to fell tired. It is recommended that the patient build up activity levels only as tolerated.

Certain activities should be avoided, such as drinking alcoholic beverages; sitting for long periods of time; driving; lifting anything (including children) heavier than 5 pounds; housework or yard work like loading/unloading the washing machine or dishwasher, vacuuming, ironing, mowing the lawn or gardening.

Always follow your doctor’s instructions and call your doctor’s office if you have questions about your recovery or what you should be doing.

What is pain?

Pain is an uncomfortable feeling that tells you something may be wrong in your body. Pain is your body’s way of sending a warning to your brain. Your spinal cord and nerves provide a pathway for pain messages to travel to and from your brain and the other parts of your body.

Receptor nerve cells in and beneath your skin sense heat, cold, light, touch, pressure, and pain. You have thousands of these receptor cells, most sense pain and the fewest sense cold. When there is an injury to your body—in this case surgery—these tiny cells send messages along nerves into your spinal cord and then up to your brain. Pain medicine blocks these pain messages or reduces their effect on your brain.

Sometimes pain may be just a nuisance, like a mild headache. At other times, such as after a surgery, pain that doesn’t go away—even after you take pain medicine—may be a warning sign that there is a problem. After your surgery, your nurses and doctors will ask you about your pain because they want you to be comfortable, but also because they want to know if something is wrong. Be sure to tell your doctors and nurses when you have pain and how much pain you are having.

Treatment Goals

People used to think that severe pain after surgery was something they “just had to put up with.” But with current pain treatments, that’s no longer true. Today, you can work with your nurses and doctors before and after surgery to prevent or relieve pain.

Pain control can help you:

• Enjoy more comfort while you heal.
• Get well faster. With less pain, you can start walking, do your breathing exercises, and get your strength back more quickly. You may even leave the hospital sooner.
• Improve your results. People whose pain is well-controlled seem to do better after surgery. They may avoid some problems (such as pneumonia and blood clots) that affect others.

What are your pain control options?

Both drug and non-drug treatments can be successful in helping to prevent and control pain. The most common ways of controlling pain control are talked about below. You and your doctors and nurses will decide which methods are right for you. Many people use two or more methods to get greater relief.

Don’t worry about getting “hooked” on pain medicines. Studies show that this is very rare—unless you already have a problem with drug abuse.

What can you do to help keep your pain under control?

These seven steps can help you help yourself.

Before surgery

1. Ask the doctor (surgeon or anesthesiologist) or nurse what to expect.

• Will I have a lot of pain after surgery?
• Where will the pain be?
• How long is the pain likely to last?

Being ready for pain helps put you in control. You may want to write down your questions before you talk with your doctor or nurse. There is a pain control plan at the bottom of this page.

2. Discuss the pain control options with your doctors and nurses. Be sure to:

• Talk with them about pain control methods that have worked well or not so well for you before (If you have had surgery before, tell them what worked and what didn’t.).
• Talk with them about any concerns you may have about pain medicine such a side effects.
• Tell them about any allergies to medicines you may have.
• Ask about side effects that may occur with treatment.
• Talk with them about all medicines you take for other health problems. The doctors and nurses need to know, because mixing certain drugs with some pain medicines can cause problems.

3. Talk about the schedule for receiving pain medicines in the hospital. Some people get pain medicines in the hospital only when they ask for it. Sometimes there are delays, and the pain gets worse while they wait. There are other ways to schedule pain medicine which seems to give better results.

• Giving the pain pills or shots at set times. Instead of waiting until pain breaks through, you receive medicine at set times to keep the pain under control.
• Patient controlled analgesia (PCA). With PCA, you control when you get pain medicine. When you begin to feel pain, you press a button to inject the medicine through the intravenous (IV) tube in your vein.

Your nurses and doctors will ask you how the pain medicine is working and can change the medicine, its dose (how much you are getting), or its timing (when you are getting it) if you are still having pain.

4. Work with your doctors and nurses to make a pain control plan. You can use the pain control form at the bottom of this to begin planning for pain control so you will feel confident you won’t be in pain after surgery. Your doctors and nurses need your help to design the best plan for you. When your pain control plan is complete, use the form to write down what is expected to happen. Refer to it after your operation and keep good records. Then keep this plan as a record if you need surgery in the future you will know what works for you.

Pain Control After Surgery

5. Take (or ask for) pain relief medicine when pain first begins.

• Take action as soon as the pain starts. It is harder to stop the pain once it starts.
• If you know your pain will get worse when you start walking or doing breathing exercises, take pain medicine first. It’s harder to ease pain once it has taken hold. This is a key step in proper pain control.
• Let your health care team know about pain methods that have worked for you in the past.
• Let them know what makes your pain better or worse.
• Tell them where you hurt and how much.

6. Help the doctors and nurses “measure” your pain.

• Everyone feels pain differently. They may ask you to use a “pain scale.” A pain scale can be pictures or ask you how bad you are hurting.
• They may ask you to rate your pain on a scale of 0 to 10. Or you may choose a word from a list that best describes the pain.
• You may also set a pain control goal (such as having no pain that’s worse than 2 on the scale).
• Reporting your pain as a number helps the doctors and nurses know how well your treatment is working and whether to make any changes in your pain control plan.

7. Tell the doctor or nurse about any pain that won’t go away.

• Don’t worry about being a “bother” to the nurses. Controlling your pain is important for your healing.
• Pain can be a sign of problems with your surgery.
• The nurses and doctors want and need to know about pain that can’t be controlled.

Stick with your pain control plan if it’s working. Your doctors and nurses can change the plan if your pain is not under control. Let the nurses and doctors know about your pain and how the pain control plan is working.

Benefits and Risks of Pain Treatment Methods

This information is provided to help you talk about your pain control options. Sometimes it is best to combine two or more methods or change the treatments slightly to meet your needs. Your doctors and nurses will talk with you about your options. The benefits of controlling your pain is that you will better be able to heal and you can get back to your normal routine quicker. Keep in mind that your pain will get better each day.

Pain Relief Medicines

Tell the nurse if you feel sick after taking pain medicine, or if you just don’t feel right. Your doctor may order a different medicine for you.

Nonsteroidal anti-inflammatory drugs (NSAIDS)

Acetaminophen (such as, Tylenol), aspirin, ibuprofen (such as, Motrin), and other NSAIDs reduce swelling and soreness and relieve mild to moderate pain.

Benefits

There is no risk of addiction to these medicines. Depending on how much pain you have, these medicines can lessen or eliminate the need for stronger medicines (such as, morphine or another opioid). Most NSAIDs interfere with blood clotting.

Risks

They may cause nausea, stomach bleeding, or kidney problems. For severe pain, an opioid usually must be added.

Opioids

Morphine, codeine, and other opioids are most often used for acute pain, such as short-term pain after surgery.

Benefits

These medicines are effective for severe pain, and they do not cause bleeding in the stomach or elsewhere. It is rare for a patient to become addicted as a result of taking opioids for pain after surgery.

Risks

Opioids may cause drowsiness, nausea, constipation,

Local anesthetics

These medicines (such as, bupivacaine) are given, either near the incision or through a small tube in your back, to block the nerves that send pain signals.

Benefits

Local anesthetics are effective for severe pain. Injections at the incision site block pain from that site. There is little or no risk of drowsiness, constipation, or breathing problems. Local anesthetics reduce the need for opioid use.

Risks

Repeated injections are needed to maintain pain relief. An overdose of local anesthetic can have serious consequences. Average doses may cause some patients to have weakness in their legs or dizziness.

Ways to Give Pain Relief Medicines

Tablet or liquid

Medicines given by mouth (such as, aspirin, ibuprofen, or opioid medications such as codeine).

Benefits

Tablets and liquids cause less discomfort than injections into muscle or skin, but they can work just as well. They are inexpensive, simple to give, and easy to use at home. Being able to control pain by taking pills or liquids is usually one of the conditions before you go can home from the hospital.

Risks

These medicines cannot be used if nothing can be taken by mouth or if you are nauseated or vomiting; sometimes these medicines can be given rectally (suppository form). There may be a delay in pain relief, since you must ask for the medicine and wait for it to be brought to you; also, these medicines take time to wear off.

Injections into skin or muscle

Medicine given by injection into skin or muscle is effective even if you are nauseated or vomiting; such injections are simple to give.

Benefits

The injection site is usually painful for a short time.

Risks

Medicines given by injection are more expensive than tablets or liquids and take time to wear off. Pain relief may be delayed while you ask the nurse for medicine and wait for the shot to be drawn up and given.

Injections into vein

Pain relief medicines are injected into a vein through a small tube, called an intravenous (IV) catheter. The tip of the tube stays in the vein.

Benefits

Medicines given by injection into a vein are fully absorbed and act quickly. This method is well suited for relief of brief episodes of pain. When a patient controlled analgesia (PCA) pump is used, you can control your own doses of pain medicine.

Risks

A small tube must be inserted in a vein. If PCA is used, there are extra costs for pumps, supplies, and staff training. You must want to use the pump and learn how and when to give yourself doses of medicine.

Non-drug Pain Relief Methods

These methods can be effective for mild to moderate pain and to boost the pain-relief effects of drugs. There are no side effects. These techniques are best learned before surgery.

Patient teaching

Learning about the operation and the pain expected afterwards (for example, when coughing or getting out of bed or a chair).

Benefits

These techniques can reduce anxiety; they are simple to learn, and no equipment is needed.

Risks

There are no risks; however, patient attention and cooperation with staff are required.

Relaxation

Simple techniques, such as abdominal breathing and jaw relaxation, can help to increase your comfort after surgery.

Benefits

Relaxation techniques are easy to learn, and they can help to reduce anxiety. After instruction, you can use relaxation at any time. No equipment is needed.

Risks

There are no risks, but you will need instruction from your nurse or doctor.

Physical agents

Ice packs, massage, rest, and TENS therapy are some of the non-drug pain relief methods that might be used following surgery.

Benefits

In general, physical agents are safe and have no side effects. TENS, which stands for transcutaneous electrical nerve stimulation, is often helpful; it is quick to act and can be controlled by the patient.

Risks

There are no risks related to the use of physical techniques for managing pain. If TENS is used, there is some cost and staff time involved for purchasing the machine and instructing patients in its use. Also, there is only limited evidence to support the effectiveness of TENS for pain relief in certain situations.

Keeping A Pain Control Record

Pain control plan for

_______________________________________________________________________________
Your name

Before surgery, I will take

_______________________________________________________________________________
Name of medicine

How I will use the medicine

_______________________________________________________________________________

_______________________________________________________________________________

After surgery, I will take in the hospital.

________________________________________________________________________________
Name of medicine

The medicine will be given to me:

__________as a pill

__________through a vein

__________as a shot

_________through a tube in my back.

I will receive the medicine:

__________at certain times

__________every__________hours for_________ days:

__________around the clock

__________when I call the nurse.

I will also use these non-drug pain control methods in the hospital and at home (list methods):

_________________________________________________________________________________

_________________________________________________________________________________

At home, I will take

_________________________________________________________________________________
Name of medicine

How I will use the medicine at home

_________________________________________________________________________________

_________________________________________________________________________________

If your heart problem was discovered by your primary care doctor, he probably referred you to a heart specialist or cardiologist. Following an exam and many tests, the cardiologist has recommended surgery to treat your heart problem and referred you to a heart surgeon. This article tells you what to expect during your visit with the heart surgeon. It explains what usually takes place before, during, and after heart surgery. If you have already met with the surgeon, go through the first part of this article to better understand everything you need and want to know before making a final decision about having the surgery.  Peace of mind is very important to your good health, a successful surgery and recovery. Your doctors want you to have all the facts so you can make the decision which is best for you.

Your visit with the heart surgeon

Your surgeon will explain the results of your tests and why surgery is being recommended. He will also explain the surgical procedure and the results you can expect. He will tell you about the risks of having or not having the surgery, the benefits of having the surgery and any options you have in place of surgery. You must consider the balance of the risks you will be taking and the benefits you will receive. Don’t be afraid of offending the surgeon or embarrassing yourself by asking questions about anything you don’t understand. The more you know, the more confident you will feel about your decision.  To help you get started, here is a list of general questions you can ask. When you ask these questions, be sure you ask how they apply to you, your heart and  your overall health.

Questions to ask the heart surgeon

These are general, basic questions to ask your surgeon. If you think of other questions, write them down and bring them with you to your office visit or call your surgeons office and ask. Go over the questions with your spouse and family. Ask if they have questions they would like to have answered. Before you leave the surgeon’s office, try to get all your questions answered—take notes! Be sure you understand everything clearly. If you think of questions after you leave, write them down and call your surgeon back. It’s also a good idea to take someone with you so they can listen and take notes, too.

• How will surgery improve my condition?
• Tell me again what happens during the surgery?
• Will I need blood transfusions? Can I donate my own blood?
• How long will surgery last?
• How long will I be in intensive care (ICU or CCU)?
• How much pain should I expect and how will pain be controlled?
• What will the scar look like?
• What are the possible complications of surgery; how likely are they to happen to me?
• Can I expect to completely recover from surgery? If so, how long will it take?
• How long will I be in the hospital?
• How long will my recovery take once I am at home?
• What will I be able to do and not do during recovery?
• Will I need special equipment when I get home?
• When can I go back to work?
• If I choose not to have surgery, will I get worse or stay the same?
• Is there another treatment that does not involve surgery?
• How long do I have to decide about having surgery?
• If I decide to have the surgery, how soon should I have it?

Making your decision

Once you have the information you need to consider all your options, you may be surprised that the best decision for you becomes pretty clear. That doesn’t mean it’s an easy decision to make, but at least it will be one you will feel good about your decision and will know what to expect as a result of the decision you make.

Types of open-heart surgery

You’re lucky to need heart surgery now and not more than 25 years ago. It wasn’t until the mid-1970s that the heart-lung machine, which takes the place of your heart and lungs and keeps you alive during the operation, could be used safely. This machine, along with improved surgical techniques, medicines, more advanced monitoring machines and more experienced surgeons have made open-heart surgery safer today.

The following are brief explanations of the types of open-heart surgery.

Coronary artery bypass graft (CABG)

Preparing vein for coronary artery bypass graft

When your heart muscle doesn’t get the blood and oxygen it needs because one or more or your heart’s arteries are clogged, your surgeon may recommend coronary artery bypass graft surgery. Part of a vein from your leg (saphenous vein) or part of an artery from your chest wall (internal mammary artery) is used to bypass the blocked area in your coronary artery. This new bypass artery improves the flow of blood and oxygen supply. It’s common to have as many as four or five bypass grafts done at one time. Neither your chest wall nor your leg will have permanent harm as a result of the vein or artery being removed.

Heart valve repair or replacement (aortic or mitral valve)

Preparing artificial valve for heart valve replacement

Your heart has four valves, one for each chamber of your heart. Each time your heart beats, these valves open and close to let blood in and out of the chambers. One or more of these valves may become damaged from a birth defect, scarring from rheumatic fever or an infection. If medicine can’t correct the problem, your doctor may recommend surgery to repair or replace the valve.

Congenital heart defect repair

A congenital heart defect is a condition that you were born with. About one-quarter of adults who have a congenital heart defect have a condition called atrial-septal defect. This is really a hole in the wall (atria) that separates the two upper chambers in the heart. The hole allows blood with oxygen and blood without oxygen to mix together. Usually, too much blood from the left atrium goes into the right atrium and then into the lungs. During surgery for this condition, the hole is closed and the two chambers are separate as they should be.

Heart muscle disease surgery

There are different kinds of disease of the heart muscle. Hypertrophic cardiomyopathy is a disease of the heart muscle that makes all or part of the heart thicker or overgrown. When your heart muscle gets thicker, it affects blood flow into and out of the heart. Sometimes, surgery can help this condition. If the septum (the wall between the ventricles) is so thick that it sticks out and blocks the flow of blood to the aorta and the rest of your body, the surgeon can remove part of the thickened septum so blood can flow freely to the aorta.

Pericarditis surgery

Pericarditis is when the sac (pericardium) that surrounds the heart becomes inflamed. Although it’s not common, this condition can keep coming back.  A surgeon can remove the entire sac from around the heart which usually stops symptoms (like pain and irritation) without causing harm to the heart.

Getting ready for heart surgery

Usually, heart surgery can be scheduled days or weeks ahead of time. It depends on how serious your heart condition is, your schedule and the surgeon’s schedule. If you have a week or two before surgery, use the time wisely. Ask your doctor about:

• Exercise — should you start, stop or continue exercises?
• Diet — should you change your diet in any way?
• Weight — would it help your recovery to lose or gain a few pounds?
• Smoking — if you smoke, STOP! Ask your doctor recommend a stop smoking program? Also ask before using nicotine replacement gums or patches.
• Medicines – what medicines should you start, stop or continue taking? Remember to ask about all medicines that you take regularly or occasionally, including prescription and over-the-counter medicines. Also ask about any food supplements you take that could cause problems with surgery.

Also, be sure to:

• Rest, relax – Take good care of your physical and mental health. Don’t overdo things. And make sure you plan some enjoyable activities to relax your mind and give your spirits a lift.
• Report health changes – Tell your doctor if you have any signs of infection, like chills, fever, coughing, runny nose, or sores within a week of your scheduled surgery. An infection may cause your surgery to be rescheduled to keep you from having complications after surgery.

A special note about smoking

Not only is smoking bad for your health, but it could affect your recovery. Since most hospitals are “smoke free”, you’ll have to quit smoking in the hospital. This means you’ll be going through nicotine withdrawal while your body is also trying to recover from surgery. Do yourself a big favor—quit smoking now, and your mind and body will be able to focus on healing and not withdrawal, too.

Making arrangements for heart surgery

Knowing which foods you’re allergic to can give clues to other things you may be allergic to but haven’t been exposed to yet, like latex.

Whether you’re having major or minor surgery, try have a family member or friend with you. Even when you are going for the pre-admission tests (explained later), it’s a good idea to have someone with you. They can listen and take notes for you — or simply hold your hand if that’s what you need!  Give your family or friend plenty of notice about upcoming tests and surgery.  Make a list of all medicines and food supplements you take and any allergies to medicines, food, etc. that you may have. Take this list with you when you go to the hospital so you don’t forget anything.

Pre-admission procedures

A week or so before surgery you’ll need to have tests. Your surgeon’s office will tell you where to go and which tests you’ll need. If you’ve had any of these tests recently, ask your surgeon if a copy of your test results will do in place of redoing the tests. Test you may need include:

• a chest x-ray to see how well your lungs work
• an electrocardiogram (ECG) and/or an echocardiogram (ECHO) that shows how your heart is working
• blood tests that show chemistry and blood counts
• a urine analysis

There will be paperwork to complete. You will be asked:

• to fill out insurance forms, or give authorization forms from your insurance company; make sure you bring your insurance card(s)
  bring a picture ID such as your drivers license
• if you brought special orders from your doctor, surgeon or lab test results
• the name, address and telephone number of someone to contact in case of emergency

You will be told about your rights for advanced directives (your options for life support if that’s needed) and asked for a copy of your living will and health care power-of-attorney. You must sign a surgical consent form. This form is a legal paper that says your surgeon has told you about your surgery, alternatives for surgery and any risks you are taking by having the surgery. By signing this form you are saying that you agree to have the surgery and know and accept the risks involved. Ask your doctor about any concerns you have before you sign this form.

Blood transfusion

Surgical methods today reduce much of the blood loss during surgery. However, you may need a blood transfusion. If so, your blood will be carefully matched with blood that has been tested. The blood you receive can come from:

• a blood bank – this blood supply is from the American Red Cross and is safer today than it has ever been
• a designated donor – this can be a family member who has the same type of blood that you do
• you (autologous blood donation) – you will give blood at a local blood bank or hospital

Ask your surgeon which would be best for you. If you give blood, you must do it in plenty of time for surgery. Also, be sure to eat and drink as directed if you decide to give blood.

Being admitted to the hospital

You will usually be admitted to the hospital the day before your surgery. Simply check in at the hospital admissions desk. The hospital should have a record of your pre-admission tests and forms that you completed. If you did not go through pre-admission procedures, you will need to have the tests and complete the forms explained in the Pre-admission procedures section above. Some hospitals will admit you the morning of your surgery.

You will be taken to your room. A nurse will take your temperature, pulse, breathing rate and blood pressure and record it on your chart.

Make sure you tell the nurse about:

• any medicines you are taking (bring a written list with you) allergies you have and allergic reactions
• any other health problems (e.g., eye or hearing problems, dentures)
• how to contact your family
• who to contact in case of emergency
• anything else that will help them care for you

The nurse will let you know if the doctor left any special orders for you to get ready for surgery (e.g., enema or suppository, antibiotic, sleeping pill, etc.). Feel free to ask questions about the hospital, your room and the equipment in it, location of bathrooms, the intensive care unit (ICU) (where you’ll be right after surgery), visiting hours, etc.

Make sure your family asks the nurse about:

• the time of your surgery and how long it might take
• where they should wait for news during and after the surgery
• where the ICU is located and how long they can visit you in ICU
• how and what should they take (e.g., clothes, toiletries, glasses, etc.) to the ICU after your surgery

The night before surgery

Usually, your surgeon and anesthesiologist will visit you the night before or early the morning of your surgery. Your doctor will confirm the time of the operation, review your medical history and do a final physical exam. Now is your chance to ask any last-minute questions or voice any concerns. The anesthesiologist will explain about the anesthesia used during surgery, ask if you have ever had problems with anesthesia during surgery, and how the respirator works.

Sometime that evening, you’ll shower or wash with a special cleansing soap.  Your surgical site will be shaved. Shaving rids the body of as many germs as possible and prevents discomfort when bandages are removed. Do not put on any powder or lotion after you wash. And remember, if you feel tired or have pain or discomfort while washing, stop and call a nurse to help you.

Last, but not least, you must stop eating and drinking by mid-night, since anesthesia is safer on an empty stomach.

The day of heart surgery

Before surgery

In the morning before surgery, you can wash your face and hands, brush your teeth, shave and put on your operating room gown. You may not eat or drink anything before surgery. Also, you’ll be asked to remove makeup, jewelry, hair pins, dentures, nail polish, contact lenses or artificial limbs. You’ll probably be given medicine that will make you a little drowsy and relaxed before you’re wheeled to the surgical suite. When you leave your room for surgery, your family or friends will go to the surgical waiting area.

The operation

In the surgical suite, you will be given a local anesthetic so an intravenous (IV) catheter (tube) can be inserted. This IV tube will supply your body with the general anesthesia that puts you to sleep during surgery and medicines. In fact, almost as soon as you begin receiving the anesthesia through this tube you’ll be asleep. There are many electrodes, catheters and tubes that are attached to or inserted in your body. These help watch your body’s functions, remove excess fluid or help you breathe during the surgery.

Open-heart surgery requires an incision lengthwise down your breastbone, called the sternum, or crosswise between your ribs. The breastbone is then pried apart. When surgery is done, the breastbone is wired back together and your skin is sewn or stapled together. If you’re having bypass surgery, you may also have an incision in your leg where your leg vein was removed. Your incision(s) may be painful for a few days, then sore for a while afterward. Ask for pain medicine if you need it.

Heart-Lung Machine takes over for your heart and lungs

While you’re on the heart-lung machine, the surgeon can repair to your heart while your heart stays still. Usually, when the major part of the surgery is over (when the repair(s) are done, you are removed from the heart-lung machine and your heart begins working again) your family will be told. You will probably stay in the surgical suite for a couple of hours for a total of several hours for the surgery and observation period. Then you’ll be moved to the ICU.

In the intensive care unit (ICU) (Sometimes called CCU – Cardiac Care Unit)

When you’re in ICU, a member of the surgical team will tell your family about the surgery and how you are doing. You’ll be groggy from the anesthesia and unable to speak because of the breathing tube in your throat. You may hear sounds from the equipment around you and hear voices that sound far away. It may be your nurse telling you your surgery is over. You will still have tubes, catheters and monitors attached to or inserted into your body from the surgery. This ICU equipment provides the staff with continuous information on how your body is recovering. You’ll probably be in the ICU for a day or two. Because the nurses are constantly checking on you, this time won’t be very restful. Also, you will have some discomfort and pain. If you need pain medicine, don’t wait too long to ask for it so that you can get the rest you need to heal. The ICU nurses keep a constant watch on your condition and do whatever else is needed to keep you comfortable.

Family visits

Your family can visit you in the ICU for brief periods even though you may drift in and out of sleep at first.  They should know you will look pale and your face may be swollen. Because your blood was cooled down for surgery, you will feel very cool and may shiver right after surgery. If your family leaves the hospital, they should let the ICU staff know how they can be reached and when they will be back.

On the road to recovery

Each patient’s recovery rate is different. How quickly you recover depends in part on your physical health before surgery and how complex your heart surgery was. The first step in recovery is breathing deeply and coughing to clear your lungs. When you can do this, your breathing tube will be removed and replaced with an oxygen mask. This could happen as soon as the day after your surgery.  Then you may be moved from the ICU to another area of the hospital. Your care will continue as follows:

• you’ll continue to have electrocardiograms to record your heart rhythm
• you’ll wear an oxygen mask as needed
• you’ll continue to have blood tests
• your fluid intake and output will be monitored
• the nurses will help you with turning in bed, coughing and deep breathing exercises
• you’ll start with ice chips and sips of fluid, then solid food

Taking part in your recovery

As you become more active, you’ll bet more involved in your recovery – even while you are still in the hospital. Here are some things you can do:

• eat right – healthy food helps you heal
• keep your lungs free of fluid, which can lead to pneumonia, by practicing your deep breathing and coughing exercises
• get out of bed as soon as you can so your muscles stay strong; start slowly sitting on the side of the bed, then the chair, then short walks, then longer walks
• do the recommended leg exercises to keep your legs muscles strong
• wear elastic or support stockings if your doctor ordered them
• use a chair with a firm back when sitting with pillows on the chair arms; raise your feet to the same height if your legs or feet swell, but don’t cross your legs (this slows blood flow)

Because of your surgery and limited movement right after, fluid can build up in your lungs. This fluid can cause pneumonia and keep you keep you in the hospital longer. Therefore, it is very important that you take deep breaths and cough often. You may be given an incentive spirometer to help you breathe correctly. To ease the pain in your chest when you cough, support your chest incision with a pillow or your hands.

Good days and bad days

After the first few days when you’ve come through the worst of it, your emotions may get the best of you. Don’t be surprised if you have good days and bad days. You may cry more easily, have bad dreams, not be able to concentrate or just feel afraid or down. Some of this is stress, lack of sleep and the effects of the anesthesia and other medicines. It’s not pleasant, but it’s normal after what you’ve been through. Don’t pretend you feel OK when you don’t. Let your family and the hospital staff know. It may help you and your family to talk to a rehabilitation counselor.

Better days ahead

As you near the end of your hospital stay, you’ll be ready to go home. Your mental outlook will improve and your physical recovery may speed up once you’re home. Family, familiar surroundings and peace and quiet can help a lot.

Before you leave the hospital, you’ll be given instructions from your cardiac health care team about a number of things. These include :

• how to care for your incision(s)
• a heart-healthy diet
• a list of physical activities you can do during the next 6-12 weeks
• exercises for you to do
• a list of special equipment, medicines or supplies you’ll need
• the date of your first follow-up visit with the surgeon

Once you’re at home, pace yourself. Follow your doctor’s instructions. Be aware of how you feel during everyday activities. You’ll know when you can increase the level of activity. When you’re tired, rest. When you’re hungry, eat – but eat heart healthy foods!

Congratulations! You’re on your way. Better days are just ahead!

When to call your surgeon

Once you get home you may feel nervous and worried about being on your own. Don’t sit and worry if you think something isn’t right about your health or how you are healing. If you have signs of a heart attack or infection call your cardiologist or surgeon. Keep their phone numbers handy. If the signs tell you it’s a life threatening emergency call 911 right away.

Your stitches or staples will be removed 10 to 14 days after surgery.  Check your incision every day. Call you doctor if you see signs of infection.

Medicines

If you had to stop taking a daily medicine, ask your surgeon when you can begin taking it again. Make sure you are aware of any possible interactions between your daily medicine and the “temporary” medicine you will be given while you are recovering. If you have any reactions as a result of taking both medicines, call your doctor immediately.

Pain medicine

The “normal” amount of pain you can expect will depend on the type of surgery. What is too much pain depends on how much pain you can stand, your age, and physical condition. Your surgeon will give you medicine for your pain and directions for taking it. If the medicine does not relieve the pain, you should call the surgeon. It is a good idea to take your medicine with food to avoid nausea. The following are side effects of some pain medicines:
• constipation
• upset stomach
• nausea, vomiting
• allergic reaction – rash, itching, hives, trouble breathing
• drowsiness – if medicine is too strong

If your pain is very bad and does not go away after taking the pain medicine, you should call your surgeon. Your family should call your surgeon if your pain medicine makes you so drowsy they cannot wake you.

Antibiotics

Your surgeon may give you antibiotics to prevent infection. If you are given antibiotics, be sure to take them as directed. Feeling better does not mean that all infection-causing bacteria have been destroyed; you must take all of the antibiotic prescribed for you. Common side effects of antibiotics:
• diarrhea
• upset stomach
• vaginal yeast infection

Diet

If at first you are sick at your stomach, you should start with a bland diet of Jell-O, rice, toast, and plenty of fluids. Then slowly increase the kind of foods you eat. To help yoUr body heal, eat nutritious foods and drink plenty of water.
Cal/your surgeon if you still have nausea, vomiting, and/or diarrhea 12 hours after you get home.

Special equipment and home safety

Before your surgery buy or rent any special equipment your surgeon said you would need, such as crutches, walker, cane, etc. These items will·help you get around by yourself. In addition to having the proper special equipment, you can prevent falls by:
• removing electrical or phone cords that lay across floors
• removing or repairing loose rugs or carpet
• cleaning up spills on bare floors
• keeping toys and magazines off of stairs and floors
• watching for pets that may jump on you or run in your path
• wearing shoes with non-skid soles
• taking pain medicine as directed
• keeping ice and mildew off of outside steps and walkways

Incision care

Your incision may have staples or stitches. These will probably be removed within 2 weeks after surgery. As your incision heals, the swelling, soreness, and bruising will improve. It may itch, but try not to scratch! Check your incision everyday for:
• drainage
• redness or swelling
• bright red blood
• opening up

Depending on your surgery you may need to keep your head, arm, hand, foot, or leg elevated. Your doctor may give you instructions for applying compression, heat, or ice. You may have a splint or cast to protect the incision and/or keep you in the correct position for healing.

Activities

It is normal to feel tired or weak after surgery. If possible, have someone stay with you for the first 24 hours. Plan on taking it easy the rest of day following surgery. It is important that you move around a little. Be sure to take deep breaths and cough at least 6 times each hour. Do not plan on strenuous activities fop a few days. You will regain your strength and stamina as you begin doing your normal daily activities. Ask your surgeon when you can:
• go back to work
• drive
• begin walking and exercising regularly
• begin physical therapy if needed

After some types of surgery it is normal to worry about resuming sexual relationships. Many times, though, advice about resuming sex is not given. However, by the time you feel like having sex again, your recovery should be well along, and you will have nothing to worry about by resuming sex. If you do have questions, the best time to ask your surgeon is at your first follow up visit.

When to call your surgeon

Most of the time surgery and recovery go smoothly; therefore, you should be able to take care of most things that happen. However, there are times when you should call your surgeon.

In case of emergency

Be sure to have handy the phone numbers of the surgical center and your surgeon. You should have an office number and a number to call 24 hours a day including weekends for each.

You are an important member of your health care team!

Having outpatient surgery means more than being a “patient”. It means being an active member of your health care team. To be a part of that team, you should work together with the doctors, specialists, nurses, and other health care professionals to make sure your surgery and recovery are as safe as possible so you will have the results you expect. To do this means you must learn about and be an active part of the surgical and recovery process. By understanding what will happen before, during, and after your surgery, you will have the confidence to take care of yourself once you are at home and on your own. Your surgery is going to be a success and your recovery rapid ifyou are determined to take charge of your health!

Important Phone Numbers

Although surgery is very safe today, things can happen. Keep a list of both day-time and 24-hour numbers for the following people:
• Your regular doctor
• Your surgeon
• The surgical center or hospital where you had surgery
• A local ambulance service
• Your pharmacy and a 24-hour pharmacy
• The name and phone number of friend or relative you can call

The balance of risk and benefit

Before you make the decision whether to have surgery, you must balance the risks you will be taking and the benefits you will receive. Think about what you need and want to know to make an informed decision. Don’t be afraid ofoffending your doctor or surgeon or embarrassing yourself by asking questions about anything you do not understand. It is important that you have the answers you need to make the decision that’s right for you. Your doctor or surgeon will be happy to answer your questions.

Making your decision

Below are questions you should ask to help you make your decision. You will probably think of others which are important to you. Write them down and ask your surgeon.

• How will the surgery improve my condition?
• What are the possible complications of surgery, and how likely are they to happen?
• How long will it take me to recover fully?
• If I choose not to have surgery will I get better, worse, or remain the same?
• Is there an alternative treatment that does not involve surgery?
• How long do I have to decide?
• If you decide to have the surgery, be sure to ask your surgeon:
• How soon should I have surgery?
• What type of anesthesia do you recommend?
• Will I need a blood transfusion?
• How long will the surgery last?
• How long will I be in the recovery room?
• How ltluch pain should I expect?
• How will my pain be controlled?
• Will I have a scar?
• Will I have any physical restrictions, such as a cast or pins, and for how long?
• Will I need special equipment when I get home?
• After surgery which activities will I have to avoid? For how long?
• Should I make any changes in my diet or exercise routine?
• Should I stop taking aspirin or aspirin products before surgery?
• Is there any special equipment I will need when I get home?
• Should I stop taking any of my regular medicines? When can I start taking them again?
• When can I go back to work?
• How soon after surgery can I drive?
• Will I need physical therapy? When should it start?

Getting in shape for surgery

Your surgery and recovery will be easier if you are in good physical shape. Ask your surgeon ifbefore surgery you should:
• exercise – walking is great for circulation and breathing
• change your diet
• lose weight
• stop or cut down on smoking; it will help your breathing
• stop taking aspirin or aspirin products
• limit your alcohol intake

If you exercise regularly, check with your surgeon to make sure that your exercising is not aggravating your condition. Also, don’t underestimate the effects of your mental outlook on healing and recovery! If your spirits need a lift – treat yourself to a movie or a favorite dinner. Gef a manicure or a new haircut.

Making arrangements for surgery

It is very important that you have someone go with you to the surgical center. You will need them to hear the surgeon’s instructions for your care at home, drive you home, and stay with you for the first 24 hours. You will not be allowed to arrive at the center alone and wait for someone to pick you up after surgery. Your surgery will be rescheduled if you do. Although you may think you will feel fine after surgery, you will be given sedatives to help you relax. After taking the sedatives, it will be illegal for you to drive. You would be a danger to yourself and others if allowed to drive in this condition.

Preparing for recovery at home

If the surgeon told you special equipment will be needed, be sure to rent or buy it before you have surgery.
Special equipment might be:
• crutches
• cane
• walker
• wheelchair
• special pillows
• seat cushions

Ask if you should bring them to the hospital with you on the day of your surgery. Think about how you might feel during your ride home and how long you will be in the car. Bring pillows, blankets, or other items to make your ride more comfortable.

When you get home, you may need medicine or supplies such as bandages, dressings, or tape. The surgical center will send you home with enough supplies to last for a couple of days. You should be able to buy more supplies at a local drug store. If your surgeon prescribes pain medicine, ask someone to go to the drug store for you as soon as you get home.

Pre-admission procedures.

A few days before surgery you will need to have certain tests. Your surgeon’s office staff will tell you where to go and which tests you will need. If you have had any of these tests recently, ask your surgeon if a copy of your test results will do in place of redoing the tests.

These tests may include:
• a chest x-ray to see how well your lungs work
• x-rays of your surgical site
• an EKG (electrocardiogram) that shows how your heart is working
• blood tests that show chemistry and blood counts
• a urine analysis

During pre-admission you may also talk with the anesthesiologist. He will ask about your previous surgical history. He may inspect your teeth, mouth, and neck to look for possible problems with anesthesia. Be sure to tell him about any loose teeth, caps, or crowns you have; ordinary fillings are not of concern. He will talk with you about the best type of anesthesia for you based on your preference, medical history, and the kind of surgery you will have.

There will be paperwork to complete. You will be asked:
• to fill out insurance forms, or provide authorization forms from your insurance company; make sure you bring your insurance card(s)
• if you brought written orders from your doctor or lab test results
• the name, address, and telephone number of someone to contact in case of emergency

You will be told about your rights for advanced directives and asked for a copy of your living will and health care power-of-attorney. You must sign a surgical· consent form. This is a legal paper that says your surgeon has told· you about your surgery and any risks you are taking. By signing this form you are saying that you agree to have the surgery and know the risks involved. Ask your doctor about any concerns you have before you sign this form.

The night before your surgery

Make a list of all the medicines you take, the dosage, and when you take them. Make a list of all the drug allergies you have. Include how you react to each drug, such as swelling or rash. Bring these lists with you to the surgical center and give them to the nurse. At least 8 hours before surgery is scheduled, you should stop eating and drinking. Usually this means “nothing to eat or drink after midnight”. The purpose for going without food is to keep you from breathing food into your lungs during surgery. This could cause serious problems during and after surgery.

If you regularly take heart or blood pressure medicine, insulin, steroids, or other daily medicine, ask your surgeon if you should stop taking it until after surgery. You may be allowed to take your medicine with just a sip of water the morning of surgery. Depending on the type of surgery you’re having, your surgeon may have you do some things to get ready the night before and/or the morning of surgery.

These things could include:
• bowel preparation with enema or suppositories
• vaginal douche
• taking certain medicine to control nausea from the anesthesia
• washing your surgical site with antiseptic soap

If you have a GPS, program it the night before or get driving directions online.

Be sure to follow any special instructions carefully or your surgery may be postponed. Get everything together the night before surgery that you will need the next day. Know what time you must leave to get to the center without rushing. Plan for traffic. Then give yourself a little extra time.

The day of your surgery

What to wear?

Wear loose fitting, comfortable, practical clothes. Jogging sweats are great for most surgery. Think about where your incision will be; shorts are great for knee surgery. Will you have large dressings, splints, or a cast? If so, wear clothes with large arm and/or leg holes. Will you be able to use both of your hands? If not, wear slip-on shoes and clothes without buttons, zippers, or ties.

Things not to wear:
• shoes that tie, have high heels, or slippery soles
• tight pants, especially if you are having abdominal or hernia surgery
• tight underwear, pantyhose, knee-high stockings
• makeup, lipstick, nail polish
• dentures, loose bridge work
• contact lenses
• jewelry of any kind

If you feel uneasy without your dentures or you need glasses to see without contacts, you may wear them to the surgical center. However, you will have to remove them before going into surgery. Whatever you bring will be kept for you until you return to the holding area. The surgical center will be careful with your things, but they can not be responsible if anything happens to them. Don’t bring valuables or things you do not need.

Admission

When you get to the surgical center, check in with admissions. Someone from the surgical team will come and take you to the surgical suite. A nurse will ask you questions about your surgical history, what medicines you are taking, and what drug allergies you have. Remember the lists you made? You will be asked when you last had something to eat or drink. Be honest! It is better to put off surgery than take a chance with having problems.

You will be asked to change into a hospital gown – nothing else. Your clothes will be kept for you or given to your family until you return. You will be asked to empty your bladder. A baseline temperature, pulse, breathing rate, and blood pressure will be taken. You will be placed on a bed with wheels and an IV started in your arm. You will be given a sedative to make you drowsy and relieve your anxiety. Your surgeon may come and speak to you, your friend, or your family before surgery. They will be shown to a waiting area, and you will be taken into the operating room or a holding area. In the holding area you may see other patients waiting for their surgery, too.

The operating room

While in the operating room a surgical team makes everything go smoothly. Your surgeon heads up the team and may have a surgical assistant. The anesthesiologist or nurse anesthetist will give you anesthesia, help position you on the operating table, and watch you during surgery. A scrub nurse will clean the surgical site with a germ killing solution. The area may also be shaved to remove hair. This nurse will also set up the instruments and assist the surgeon during surgery. A circulating nurse will make sure all supplies are available and assist the surgical team.

Before surgery begins, several monitors will be attached to your body. A blood pressure cuff will be placed on your arm to monitor your blood pressure. A temperature monitor will be attached to your skin. You will have patches with wires that will monitor your heart’s rhythm and rate. Also, a monitor for the oxygen level in your blood will be attached to you.

Anesthesia

Your surgeon and the anesthesiologist will use the best method of anesthesia for you. Some surgeries call for a certain method ofanesthesia, but in most cases your personal preference can be considered. Generally, surgery is done using the least amount ofanesthesia that allows the surgeon to operate and keeps the patient comfortable.

An anesthesiologist or nurse anesthetist is always present during your surgery. While your surgeon is focusing on your surgery, the anesthesiologist is focusing on you. He is watching your temperature, heart rate, breathing, blood pressure, and oxygen monitors. These monitors are so accurate and sensitive they can instantly detect the slightest change in your body.

There are three methods of anesthesia. They range from just being numb in a small area to being completely asleep. With local anesthesia the anesthetic is injected around the surgical site, making it numb. With regional anesthesia a specific part ofthe body is numb such as from the waist down.

Regional anesthesia includes epidural anesthesia (medicine injected into your back) and spinal anesthesia (medicine is placed in the spinal canal). Regional anesthesia can also numb an arm or a leg and is often used for hand or foot surgery. With general anesthesia you will be completely asleep. Just before surgery a premedication will be given to you to calm you down. During surgery you will be kept asleep with anesthetic gas or injections. Whichever type of anesthesia is used, rest assured that the surgery will be pain free.

The recovery room

When your surgery is over, you will be taken to the recovery room. Your surgeon will tell your family about your surgery and how you are doing. A specially trained nurse will watch you carefully until you recover from the anesthesia. The nurse will watch your blood pressure, pulse, temperature, and breathing. You will still have an IV in your arm and maybe an oxygen mask. The monitors will be removed as you recover.

You will slowly wake up after a half-hour to an hour. At first you will feel sleepy. You may be sick at your stomach, have blurry vision, dry mouth, or chills. Let your nurse know how you feel. If you are in pain tell the nurse how much and where you hurt. You may be given something to relieve your pain. Your nurse may give you ice chips or sips of water to help decide when you will be able to drink liquids.

After you are wide awake and your vital signs are stable at a normal level for you, you will be taken to a holding area. There a nurse will continue to check your progress. Your friend or family will be allowed to see you now.
The nurse will follow your progress by:
• checking the surgical site for bleeding or swelling
• checking your blood pressure and temperature
• making sure drainage tubes are working

As your body recovers, you may feel some pain. If so, tell your nurse you would like some pain medicine. After you fully recover, the IV will be removed and you will be taken back to the pre-surgical area to get dressed.

Discharge

When the medical staff decides you are ready to go home, your nurse will go over the surgeon’s orders with both you and the person who will take you home. These orders will include:
• when to take off your bandage
• when to take a shower or bath
• how to care for your cast, bandage, and/or drainage tubes
• how to put on a new bandage
• what medicines to take and why
• signs and symptoms of infection
• whom to call in case of emergency
• how to use any special equipment you need
• when to see your surgeon for a follow up visit
• any physical or activity restrictions

Ask the nurse to explain any instructions you do not understand. It is very important for you to follow your surgeon’s orders once you get home. How fast you recover will depend a lot on the kind of surgery you will have had and your mental approach to recovery. This includes doing everything your health care team asks you to do.

Alcohol and drugs don’t mix!

There are many kinds of surgery done under general anesthesia. With general anesthesia, you are “put to sleep” and your breathing is slowed down and the breaths you take are not as deep as you normally take when you are up and active. These shallower breaths keep the little air sacs in your lungs from filling with air. These sacs can flatten and their insides stick together like a water balloon after you let the water out. In order to get air back into these sacs, you need to take deep breaths and hold them. Holding your breath makes the little air sacs pop apart and fill with air. If you don’t get the little air sacs filled with air you may have complications like pneumonia.

Deep breathing exercises can also help relax you and relieve pain. If you had chest or abdominal surgery, press a pillow firmly against your incision to reduce the discomfort from deep breathing and coughing. If you’re in too much pain to take deep breaths and cough, let your doctor or one of the nurses know so your pain can be better controlled.

Breathing and Coughing Exercises

Practicing these breathing exercises before you have surgery will make it easier to do them afterward—and you’ll be less likely to have lung problems.

If you know you are going to have general anesthesia, you can learn and practice breathing and coughing exercises before you go. If you had emergency surgery, be sure to do the breathing and coughing exercises after your surgery while you are on bed rest and are unable to get up and walk around. These exercises are particularly important if you had abdominal or chest surgery or your are prone to lung problems.

Breathing Exercises

After you have surgery with general anesthesia you need to do breathing exercises. Doing these exercises will help prevent lung problems such as pneumonia and bronchitis. The breathing exercises include deep breathing and coughing. Learn and practice these exercises before surgery; practice everyday for at least a week before your surgery.

Deep Breathing
The purpose of deep breathing is to completely fill your lungs with air. Use your chest and stomach muscles to breathe the right way.
1. Breathe in through your nose as deeply as you can (your stomach should go out as you breathe in). Hold your breath for 5-7 seconds.
2. Let your breath out through your mouth slowly—take twice as long to breathe out as you did to breathe in. Purse your lips (like you’re blowing out a candle) as you breathe out. Your stomach should go out as you breathe out.

Do this exercise 10 times. After you do the deep breathing exercise, do the coughing exercise.

Coughing
Coughing helps keep your lungs clear.
1. Take a slow, deep breath in through your nose. Try to fully expand your chest and back.
2. Breathe out through your mouth; you should feel your chest sink down and in.
3. Repeat 1. and 2. for a second breath.
4. Take a third breath, but instead of breathing out, hold your breath for a moment and then cough hard forcing the air out of your lungs.

Do the coughing exercise 3 times. Do the combined breathing and coughing exercises every hour while your awake.

Incentive spirometer
Some hospitals give out an incentive spirometer (image right) to help you do deep breathing exercises before and after surgery. Someone will show you how to use the incentive spirometer when you get it. If you’re given an incentive spirometer before surgery, don’t forget to bring it to the hospital with you when you come for surgery.

How to use the incentive spirometer

• Sit up as straight as you can. If you’re in a hospital bed, sit on the edge of your bed or raise the head of your bed so you’re sitting up straight.
• Hold the incentive spirometer in an upright position. (see picture above)
• Put the mouthpiece in your mouth and close your lips tightly around it forming a seal.
• Breathe in slowly and as deeply as you can to raise the piston in the air cylinder up to the top of the cylinder.
• Hold your breath as long as you can (at least 5 seconds), then let the piston fall to the bottom of the air cylinder.
• Rest for a few seconds and repeat the steps above at least 10 times every hour while you’re awake.
• After each set of 10 deep breaths, do the coughing exercise above to keep your lungs clear.

Once you’re able to get up and walk around, take some deep breaths and cough well as you walk. You may stop doing the breathing exercises or using the incentive spirometer once you’re up and around (unless your health care teams tells you to keep doing the exercises). If you’re unable to get up and move around at home, do your breathing exercises on the days you’re inactive.

If You Smoke

Nicotine slows down the healing process. Quitting smoking even a week before surgery can lower your risks of having surgery. Rather than have the stress of nicotine withdrawal while your body is recovering from surgery, try to quit smoking a few weeks before surgery. Talk with your surgeon before using nicotine replacement products such as a patch, gum, or cigarette substitute or to help you find ways to quit.

Are You a Candidate for Minimally Invasive Total Hip Replacement?

To be a candidate for total hip replacement:
• your hip pain should be bad enough to interrupt your sleep
• medicines no longer relieve the pain
• the pain limits your ability to do activities of daily living and social or workplace activities
• the function of your hip is impaired by your condition (arthritis, etc.)

In addition to the above, you must also have healthy bone and be willing to take part in physical therapy. Minimally invasive surgery cannot be used for revisions or fractures involving a previous hip implant.

Traditional surgery is indicated if you are morbidly obese or have severe deformities of the femur. You are morbidly obese if you have:
• a body mass index above 40 or more than 100 pounds overweight
• a body mass index above 35 and have diabetes, high blood pressure, heart disease, some cancers, osteoarthritis or other unhealthy conditions

The artificial implants used for minimally invasive surgery are the same as those for the traditional surgery.

Transient ischemic attacks (TIAs) produce stroke symptoms but resolve within 24 hours. Most TIAs resolve within an hour of onset. People that have TIAs are at increased risk for peripheral and coronary artery disease and a later heart attack or stroke.

Anatomy of the Carotid Arteries

There are two main blood vessels, the left and right common carotid artery, that are the main blood supply to the neck and head. The left carotid arises directly from the aortic arch (the major artery of the heart) and the right from the brachiocephalic artery. The two common carotids divide to form the external and internal carotid arteries. Arteries are blood vessels that carry oxygenated blood.

The external carotid supplies blood to the head. It branches from the top of the common carotid and goes behind the mandible towards the rear of the parotid gland. The internal carotid supplies blood to much of the cerebral hemisphere, the eye and the orbit. It begins about the level of the trachea (windpipe) and runs up the neck and into the base of the skull.

Carotid Artery Disease

Carotid atherosclerotic disease is associated with 15% of ischemic strokes.

Carotid artery disease is when the carotid arteries get clogged with fatty deposits, called plaque. Plaques are made of cholesterol, calcium, fibrous tissue and other cellular debris that build up in the artery. The process of fatty materials depositing on the artery walls (plaque build up) is called atherosclerosis. The amount of plaque depends on your family history (heredity), age and/or your lifestyle. Other factors like smoking, high cholesterol, high blood pressure, and diabetes can worsen the build up of plaque on the artery walls causing stenosis or narrowing of the arteries.

The blockage usually develops slowly and there are no signs until you have a transient ischemic attack (TIA) also called a ministroke. The milder form of stroke, a TIA , is caused by a lesser narrowing of the arteries so the blood supply to the brain is partially reduced.

Eventually, the blockage of the carotid arteries can lead to stroke (cerebrovascular accident). A stroke is when the blood supply to the brain is either reduced or completely stopped due to severe blockage (stenosis) in the carotid artery.

Treatment for carotid artery disease is often a combination of lifestyle changes (stopping smoking and changes in diet), and taking medicine to prevent or reduce the plaque build up. In severe cases, treatment can include surgery to remove the plaque and fatty deposits or place stents in the arteries to open up artery to increase the blood flow to the brain.

Signs and Symptoms of Carotid Artery Disease

Carotid artery disease doesn’t produce any signs or symptoms in its early stages. You may not know you have it until your arteries have narrowed enough to cause a TIA or stroke.

The symptoms of a TIA or Stroke:

• Fainting spells, lightheadedness or blackouts.
• Sudden and/or persistent severe headache. People with stroke often say they have the worst headache of their life.
• Difficulty speaking such as slurring or total loss of speech.
• Problems with your vision or blindness.
• Confusion or difficulty in understanding.
• Loss of balance, trouble walking.
• Sudden numbness/weakness and/or paralysis of the face, arm and leg which usually affects only one side of the body.

If you have any of these symptoms you might be having a stroke—you should get medical help right away. Even if they go away, don’t ignore the symptoms. Getting medical help may prevent a stroke.

Usually the symptoms last less than an hour, in which case you should see your doctor; a TIA is a sign that you are at high risk for a stroke and you should get treatment.

Risk Factors for Carotid Artery Disease

• Age. As we get older, our arteries become less elastic and more prone to injury.
• High blood pressure. High blood pressure is an important risk factor for carotid artery disease. Too much pressure on the artery walls can weaken them and make them easier to damage.
• Smoking. Nicotine can irritate the inner lining of your arteries. It can increase your heart rate and raise your blood pressure.
• Too much fat in your blood. High levels of low-density lipoprotein (LDL) cholesterol and triglycerides can cause plaque to build up faster.
• Diabetes. Diabetes affects your ability to handle sugar and your ability to process fats putting you at a higher risk for high blood pressure and atherosclerosis.
• Obesity. Carrying around too much weight increases your risks for high blood pressure, atherosclerosis and diabetes. Being overweight can also make you less active and more prone to injuries exercise injuries.
• Heredity. A family history of atherosclerosis or coronary artery disease increases your risk of carotid artery disease.
• Not enough exercise. Lack of exercise contributes to many health problems, including high blood pressure, diabetes and obesity.

The more of these factors you have, the more likely you are to develop carotid artery disease.

Diagnosis of Carotid Artery Disease

Before starting treatment, your doctor has to determine how much narrowing and blockage you have. Stenosis can be found during a physical examination by using a stethoscope to check the sound of the blood flow in the carotid artery. When there is narrowing of the artery, the blood rushes through the artery which makes a sound called a “bruit.”

If you have symptoms or a history of a TIA or stroke your doctor can more easily identify the stenosis and plan treatment. If you have not had a TIA or stroke, other tests are done to find out how much stenosis you have. These tests include:

Doppler ultrasound – Ultrasound waves are sent to the tissues and the blood flowing in the arteries, which bounce back as echoes and translated into images.

Oculoplethysmography (OPG) – This is an indirect process, where the pulse of the arteries behind the eyes is measured the amount of blockage in the carotid artery.

Computed tomography (CT) scan or computer-assisted tomography (CAT) scan – This is a process of taking many cross-sectional x-rays of the head and brain. This scan also an indirect process as the test does not identify blockage or stenosis, instead it eliminates other problems that cause similar symptoms.

Arteriography – Also called Digital Subtraction Angiography (DSA). In this process a dye is injected into the patient’s vascular system and then xrays are taken of the carotid arteries. This process has risks since it is an invasive procedure, but it gives an accurate diagnosis.

Magnetic Resonance Angiography (MRA) – With the help of computer software and a powerful magnetic field, a detailed image of the arteries is created. An MRI is not an invasive procedure but is a very accurate one.

Treatment of Carotid Artery Disease

How your doctor treats the disease will depend on how narrow your arteries are the symptoms you’re having. If your arteries have mild narrowing, your doctor will likely treat you with lifestyle changes and medicine to prevent further plaque build up.

• Lifestyle changes. Stop smoking, lose weight if you need to and exercise are all changes you can make to lower your risk and stop the progression of carotid artery disease. It is also very important that you manage a chronic health condition, especially high blood pressure, high cholesterol and diabetes.

• Medicine. Daily aspirin therapy or other blood thinning medicines can help keep blood clots from forming. Blood pressure medicine may be needed if losing weight and exercise are not enough.

If the narrowing in your arteries is severe enough to cause TIAs or a stroke, then surgery to remove the blockage will be recommended. Your doctor may recommend a vascular surgeon for a carotid endarterectomy or angioplasty with a stent implant. Carotid endarterectomy is the most common treatment for severe narrowing. There is low risk with this surgery if you are otherwise healthy.

If the blockage of the artery is located in an area that the surgeon can’t get to with surgery, then angioplasty and stenting may be recommended.

Carotid Endarterectomy

If your disease requires surgery a vascular surgeon will likely perform the operation. Tests are often done to find out if there is stenosis in other arteries and whether your have other health problems related to high blood pressure or heart diseases. If these tests show that the risks of surgery are too high, the surgeon may postpone surgery.

If you are OK for surgery routine blood and urine tests will be done. You may also have an EKG and chest xray to see if you are otherwise healthy enough for surgery and anesthesia.

The surgery begins with an incision on the neck down to the carotid artery. A temporary rerouting of the artery is done while the surgery is in process. The plaque and fatty deposits are removed from the walls of the arteries. The arteries are stitched back into position. Sometimes arteries need to be patched with either artificial materials or with a vein graft taken from the patient’s leg. When the surgery is finished the neck incision is closed.

How long you stay in the hospital depends on your overall health before surgery, how well you tolerated the surgery and how soon you recover enough to go home.

After Carotid Endarterectomy

After surgery, the patient usually stays in the hospital for a couple of days to watch for complications. Then the patient is discharged with instructions to avoid strenuous activities and slowly increase the level of activity as tolerated. The patient is also given instructions for a low-sodium, low-fat diet, to do moderate exercise, and quit smoking as these lifestyle changes will help avoid the risk of the artery becoming blocked again.

Carotid Stenting

This procedure is relatively new and is still evolving. A long thin tube is inserted in the groin and moved up the aorta, behind the heart and to the carotid artery using xrays as a guide; instruments are moved through the artery inside the tube to the blocked area. An angiogram (xrays with dye) is taken of the artery. A filter is used to keep the plaque from breaking off and going to the brain and causing a stroke. With angioplasty and stenting a catheter with a balloon is inserted in to the narrowed artery and inflated to open up the artery. Then the balloon is deflated and removed. Then a stent (a small wire mesh) is fed up the artery with a catheter into the opened up area with a guide wire and left inside the artery to keep the artery open. The catheter is taken out leaving the stent in place. A balloon opens the stent further and widens the artery. The balloon is removed leaving the stent in place to hold the artery open. An after angiogram is taken and compared to the before angiogram. If the result is good, the filter and instruments are removed and the puncture site in the groin is closed.

Discharge Instructions

When you get home:

• Take blood thinner medications as prescribed to prevent blood clots from forming on the stent. These medications can make you to bruise more easily.
• Shower instead of taking tub baths for a few days.
• Don’t lift anything over 10 pounds for a few days.
• Take it easy, but get back to your normal routine as much as you can.
• Talk to your doctor before driving, returning to work, and other activities you are concerned about.

Risks and Complications

All surgery has risks and sometimes complications (like bleeding, infection, scarring, complications from anesthesia, etc.), carotid endarterectomy can have its own complications of the esophagus (food pipe), trachea (air tube), vocal cords and even the nerves of the face, mouth or tongue. Because these are very close to the surgical site, although rare, there is always a possibility of damaged during surgery.

There is also the possibility of a that a blood clot from the endarterectomy may block another artery causing an embolism or even a stroke.

The severity of the complications depends on the patient’s age and their overall health.

Preventing Carotid Artery Disease

In order to prevent a stroke, the risk factors for stroke should be eliminated or controlled. These risk factors include:
• smoking
• high blood pressure
• high blood sugar
• heart disease

When these factors are controlled, the chances of a stroke can be significantly reduced.

Certain nutritional supplements are known to reduce the homocysteine level (an amino acid that is one of the causes of plaque formation), increase the oxygen level in the blood and improve the blood circulation. These are folic acid; vitamins B6, B12, C and E; angelica (a herb known for its anticoagulant or blood thinning properties). Ask your doctor if you should take these supplements or a daily vitamin.

Though carotid endarterectomy is a safe and effective procedure to remove plaque from the carotid arteries, it is always better to do what you can to prevent plaque from forming.

The main types of anesthesia include:
• General – where you are “asleep”
• Regional (spinal and epidural) – where an entire area is numb, and you may also be sedated
• Local – where a specific area is numb

Anesthesia is performed by an anesthesiologist or by a nurse anesthetist under the supervision of an anesthesiologist. After consulting with the surgeon and patient, the anesthesiologist will decide on which type of anesthesia to use. The type of anesthesia used depends on:
• what kind of surgery the patient is having
• how long the surgery will last
• location of the surgery (where in the body)
• how intricate the surgery will be
• the age and overall health of the patient
• the anesthesiologist’s personal expertise, judgment and preference.

The goals of anesthesia are:
• loss of consciousness
• to block the patient’s memory of the procedure
• to maintain the body’s physiologic stability
• to prevent or reduce pain
• to relax the skeletal muscles
• to stop the body’s normal reflexes

Balanced anesthesia uses a combination of anesthetic agents that enhances the desired effects and limits the undesired side effects. Balanced anesthesia is usually started by giving anesthetic agent through their I.V. followed by breathing in a second anesthetic agent that quickly induces anesthesia. Anesthesia is then maintained during surgery through a breathing tube (endotracheal tube) or mask.

Sedation and Anesthesia

Sedation is the state of being calmed. Types of sedation include
• conscious sedation
• moderate sedation
• deep sedation

There are 4 levels of sedation and anesthesia when a patient receives moderate or deep sedation or general or regional anesthesia. Some of the drugs used to induce anesthesia can be given in a lesser amount to produce sedation.

Level 1 (minimal sedation) – the patient is able to maintain normal breathing and heart function is normal.

Level 2 (moderate sedation) – consciousness is reduced, but the patient responds to verbal commands. He can breathe on his own and heart function is maintained without help.

Level 3 (deep sedation) – the patient can respond to repeated painful stimuli, he can’t be aroused easily. The patient may need help breathing but the heart function still remains normal.

Level 4 (general anesthesia) – The patient loses consciousness and can’t be aroused even with painful stimuli. He needs assistance with breathing. The muscle function is depressed and heart function may be impaired.

General Anesthesia

General anesthesia consists of 4 stages; each stage causes changes in breathing, muscle tone, and reflexes. Stage 4 is an overdose and can end in death. During surgery, the patient proceeds through the first 3 stages:
Stage I – Analgesia
Stage II – Excitement
Stage III – Surgical anesthesia (which has 4 planes)
Stage IV – Medullary depression

Inhalation agents are gases or vapors that work mainly by depressing the central nervous system. They cause unconsciousness, relax the muscles and make the patient unresponsive to pain. These agents can impair breathing and blood flow, depress the heart muscle and impair kidney and liver function.

Anesthetic Agents

• Inhalation agents – these are vapors or gases used to induce or maintain anesthesia that the patient usually breathes through a tube or mask. They work by depressing the central nervous system. They also impair breathing, heart function and may affect renal and liver function.

Other side effects include over reaction to the medicine, confusion, sedation, nausea, vomiting, abnormal heart rhythm, and a drop in body temperature.

• I.V. Agents – these are commonly combined with inhalation agents for numbing, muscle relaxation and inducing general anesthesia. For short surgeries or when short acting anesthesia is needed, I.V. agents may be used without inhalants. I.V. agents include:
- Barbiturates and Non-barbiturates – Side effects of barbiturates and non-barbiturates include depressed breathing, cough, hiccups, muscle twitching, and spasm of the laryngeal cords.

- Benzodiazepines – Side effects of benzodiazepines (Valium, Versed) – drowsiness, confusion, dizziness, weakness, headache, tremors, eyes crossing, clumsiness, and trouble thinking or speaking.

- Opiods (narcotics) – The side effects of opioids are depression of the central nervous system, difficulty breathing, breathing slower than normal or shallow breathing, abnormal heart rate or rhythms, constipation.

- Dissociative agents – Side effects of dissociative agents are delirium, hallucinations, disorientation, excitement, high blood pressure, rapid heart beat, and increase in intracranial pressure.

What to Expect with General Anesthesia

Before General Anesthesia

Before you have general anesthesia, an anesthesiologist will talk with you about:
• Your health history including whether you have had surgery before
• Any prescription medicines, over-the-counter medicines and herbal supplements that you take
• Any allergies to food or medicine that you have
• Your past experience with anesthesia, such as side effects or reactions
This information will help the anesthesiologist choose the anesthetics that will work best and cause the least unwanted side effects for you.

During General Anesthesia

In most cases, anesthesia is started with an anesthetic delivered through an I.V. in your arm. Sometimes it can be started with a gas that you breathe from a mask. Once you are asleep, a tube (endotracheal tube) may be inserted in your mouth and down your windpipe to make sure you get enough oxygen and protect your lungs from blood or body fluids. Sometimes a breathing tube isn’t needed, which reduces your chance of having a sore throat after surgery.

A member of the anesthesia care team monitors you continuously during your procedure, adjusting your medications, breathing, temperature, fluids and blood pressure as needed. Any abnormalities that occur during the surgery are corrected by administering additional medications, fluids and, sometimes, blood transfusions.

After General Anesthesia

When the surgery is complete, the anesthesia drugs are discontinued, and you gradually wake up, usually in the operating recovery room. You’ll probably feel groggy and a little confused when you first wake up but you shouldn’t feel much pain from the surgery. Other common side effects include:
• Nausea
• Vomiting
• Dry mouth
• Sore throat
• Shivering
• Sleepiness

Risks of General Anesthesia

Most healthy people have general anesthesia and don’t have any problems. However there is a small risk of complications and, rarely, even death. Your chances of having a specific complication is related to your age and overall physical health, the type of anesthesia and surgery that you have.

The following factors can increase your risk of complications:
• Alcohol use may make you susceptible to liver damage
• Allergies to food or medicine
• Family or personal history of bad reactions to anesthesia
• Health conditions with your heart, lungs or kidneys
• Sleep apnea (you stop breathing while you’re asleep)
• Smoking increases your chances of having lung and breathing problems
• Medicines that keep your blood from clotting, such as aspirin and NSAIDS
• Very overweight

The following complications are rare and happen more often in adults over 65 or people with health conditions:
• Death
• Heart attack
• Lung infections
• Stroke
• Temporary mental confusion

Regional Anesthesia

Regional anesthesia blocks the sensation in either a nerve or a region of the body. Regional anesthesia is sometimes called local anesthesia or nerve block. Types of regional anesthesia include spinal anesthesia, saddle block, nerve block. There are several kinds of regional anesthesia; the two most common are spinal anesthesia and epidural anesthesia.

In regional anesthesia, your anesthesiologist makes an injection near a cluster of nerves to numb the area of your body that requires surgery. You may remain awake, or you may be given a sedative, either way you do not see or feel the actual surgery taking place.

Local Anesthesia

In local anesthesia, the anesthetic medicine is usually injected into the tissue to numb a the specific area of your body, such as an episiotomy.

Anatomy

The gallbladder is a small pear-shaped, gray-blue*, sac-like organ located on the under-surface of the right lobe of the liver in the upper right quadrant of the abdomen. Ducts (tubes) connect the gallbladder to the small intestine (duodenum). The gallbladder is divided into the fundus, body and neck. The liver makes 3-5 cups of bile every day. The main function of the gallbladder is to collect and store the digestive juice called bile that is secreted by the liver. The bile is then passed through cystic ducts into the bile ducts and ultimately into the intestine to aid in the digestion process when food is eaten, especially fatty foods. When the gallbladder is taken out, this function is taken over by the liver and its ducts. Problems with the gallbladder interrupt the total functioning of the digestive system. (*shown as green in the image)

Gallbladder problems include:

• cholelithiasis (gallstones), where solid components of the bile from stones of various sizes. Gallstones can get in the bile duct, blocking the flow of bile causing swelling of the gallbladder and pain in the abdominal area. Cholelithiasis is associated with abdominal pain in the right upper quadrant all the way up to the right shoulder and may occur after fatty meal. Symptoms of jaundice may also go with cholelithiasis. Gallstones are found in about 15% of men and 30% of women in the U.S.

• cholecystitis, which is the inflammation of the gallbladder due to infections. The most common symptoms of cholecystitis is sharp abdominal pain on the right side along with nausea, bloating, fever, vomiting and jaundice if gallstones are in the common bile duct. Cholecystitis can happen suddenly (acute) or over a longer period (chronic).

• perforated gallbladder is a condition where the gallbladder leaks or bursts. This happens rarely, but it can be life threatening.

Gallstones are usually diagnosed by ultrasound—a safe, painless, and non-invasive technique that uses high frequency sound waves to create an image of the gallbladder and gallstones. In order to relieve symptoms and complications, the gallbladder is removed surgically, called cholecystectomy.

Cholecystectomy Procedure

Cholecystectomy is the surgical removal of the gallbladder. More than 500,000 procedures are performed each year in the U.S. Cholecystectomy is usually done for gallstones and can be performed in two ways:
• open cholecystectomy
• laparoscopic cholecystectomy

Risks, Benefits, and Complications of Cholecystectomy

The benefit of having your gallbladder removed is relief of pain and most likely stop gallstones from coming back. If you don’t have gallbladder surgery, you risk the possibility of your symptoms getting worse, infection or the gallbladder bursting and infecting your abdominal cavity. Although there is some risk with all surgery, gallbladder removal is a very common surgery and the risks are small. Possible complications involved in open cholecystectomy are:
• bleeding
• injury to the common bile duct
• numbness
• raised scars
• hernia at the incision site
• puncture of the intestine
• wound infection
• abscess formation
• respiratory problems (pneumonia)
• deep vein thrombosis (blood clots)

Risks are lower with laparoscopic cholecystectomy. However, while inserting instruments and performing surgery, there is risk of injury to the common bile duct, which is the connection between the liver and the gallbladder. Minor injuries to the common bile duct are treated non-surgically, but major injuries can cause severe infection and pain and need corrective surgery.

Preparing for Cholecystectomy

Like any other surgical procedure, you will have to sign an informed consent that says you understand the procedure, its risks and potential complications and agree to have the surgery.

You shouldn’t have anything to eat or drink after midnight before the day of surgery. You can usually take your daily medicines on the morning of surgery with a sip of water. Talk to your surgeon before taking blood thinners that morning.

Anesthesia

Both surgical techniques are done under general anesthesia by a general surgeon. You will meet with the anesthesiologist before your operation. Be sure to let them know any problems you have had in the past with anesthesia or surgery. Also let them know if you:
• have any allergies
• have loose teeth or dental work
• have heart or lung disease
• have any health condition including stomach problems
• smoke, use alcohol or drugs
• take vitamins or supplements
• take daily medicines and what those are

With general anesthesia you will be asleep during the surgery and will not feel any pain.

What to Bring to the Hospital

• Insurance card and picture identification (driver’s license)
• Advance Directives
• Your glasses or dentures
• Loose fitting, comfortable clothes
• List of any medicines you take every day

Do not bring anything of value to the hospital such as jewelry, money, or electronics. The hospital will not be responsible if they are lost or stolen.

Prior to Cholecystectomy

You will get an ID bracelet on admission and taken to a presurgery area to change into a gown and have an IV placed in your arm or hand. The IV will be used to give you medicines and fluids. You may receive medicine to help you relax before they take you to surgery.

Open Cholecystectomy

This is the older procedure involving a 4 to 6 inch up-and-down incision in the right upper portion of the abdomen, or a slant incision just below the ribs on the right side. The peritoneum is cut and the gallbladder is removed. The incisions are then closed. In order to prevent accumulation of fluid at the incision site, drains may be used. The drain is usually removed in the hospital. The procedure takes about 1-2 hours. If there are no complications following surgery, you will be in the hospital for one to three days followed by 4 weeks’ rest at home before you can get back to your normal lifestyle. In more complicated cases, it may be 4 to 8 weeks before you get back to normal activity.

Laparoscopic Cholecystectomy

Laparoscopy – shows instruments in the abdomen and the abdomen distended from the gas pumped inside.

Laparoscopic cholecystectomy, often called “lap choly” is the latest procedure and is extensively used worldwide. During laparoscopic cholecystectomy, the surgeon makes four very small incisions (slits) of less than half an inch each. One slit is at the belly button, two are on the right side below the ribcage, and one is in the upper portion below the sternum, or breastbone. A tube is inserted into one of the slits and the abdominal cavity has been filled with carbon dioxide gas to inflate the area so the surgeon can see to work inside. A laparoscope is inserted in one of the other slits. A laparoscope is long tube with a small video camera and light on the end. This camera is connected to a video monitor, where the surgeon gets a good view of the organs and can do the surgery accurately. The other incisions are used to insert various instruments to grasp and remove the gallbladder. The surgeon guides the laparoscope while watching the view it provides on a video monitor. The gallbladder is separated from the common bile duct and removed with a grasper tool through one of the incisions. Once the gallbladder is removed, the carbon dioxide gas is removed and all incisions are sutured or closed with tape strips. The procedure takes 1-2 hours.

In about 1 in 30 to 40 cases, the surgeon may start with laparoscopic surgery, but complications may cause the technique to be changed to open surgery. Complications include a severely diseased gallbladder, not being able to see the organs clearly, or the instruments cannot be used without risks. It’s important to know that even though you are expecting to have a laparoscopy, there is a chance of having an open cholecystectomy.

The need to convert from laparoscopic to open surgery is more common if:
• you are over age 65
• male
• have a history of acute cholecystitis
• have had prior abdominal surgery
• have a high fever or high bilirubin
• repeated gallbladder attacks
• other diseases that limit your activity

After Cholecystectomy

You will be taken to the recovery room until you wake up and are past any problems from the surgery. Careful attention is given in recovery as with any major surgery. Your blood pressure is monitored closely as well as your pulse, breathing and temperature.

Moving and deep breathing will help prevent fluid in your lungs and pneumonia. An effective way to breath deeply is to take a deep breath and hold it for 5 seconds. Take 5 to 10 deep breaths every hour while you are awake. Because of the anesthesia and not moving around, your risk of getting blood clots in your legs is increased. During surgery you may have had sequential compression stockings to help prevent blood clots. After surgery, it is important to get up as soon as possible and walk around to prevent blood clots.

It’s normal to feel tired for several days and you may need more sleep than usual. Don’t drive until your pain is under control without narcotics and your surgeon says it’s OK.

After Open Cholecystectomy

You may not be able to breathe deeply due to the effects of anesthesia or because of pain. Pain medications will be given to relieve pain. Be sure to let the nurses know if the pain medicine is not working. Controlling pain is very important; you want to feel like moving around and taking deep breaths, which will help prevent complications that can make your recovery take longer. Doing deep breathing exercises is very important in preventing pneumonia. The nurses will show you how to support to the incision with a pillow (splinting) while doing deep breathing exercises or coughing. Your incision site is checked for drainage and infection.

Your diet will start as intravenous fluid and then slowly you will be given a regular diet as your bowel activity returns to normal and any nausea has stopped. It’s normal to have loose bowel movements for a few days after surgery. Pain medicine can cause constipation. If you are constipated increase the fiber in your diet or try a stool softener. Foods high in fiber include grains, fruits and beans.

You will go home in about 3-5 days. Slowly increase your activities. Do not lift of do any strenuous activity for 3-5 days. Returning to normal activities takes four to six weeks after surgery depending on your overall health and whether you had any complications.

Wound Care. Do not soak in a bathtub until your stitches or staples are removed and your wound has healed. It’s OK to take a shower unless your surgeon tells you not to. Protect the new skin of your incision from the sun as it can cause darker scarring; keep it out of the sun or wear sun screen for at least a year. Wear clothes that don’t rub against your incision. Change your bandages just as your surgeon prescribes and always wash your hands before and after touching near your incision site. Your scar will heal in about 4 to 6 weeks; it will get softer and fade over the next year. The feeling around your incision will come back in a few weeks or months.

After Laparoscopic Cholecystectomy

Pain from surgery can probably be controlled with pills. The abdominal pain can be accompanied with nausea and/or vomiting. Let the nurses know if you are nauseated; they can give you medicine to relieve the nausea. Liquids are OK to drink within 6 to 8 hours of surgery; solid food is allowed the day after the surgery. Pain medicine can cause constipation. If you are constipated increase the fiber in your diet or try a stool softener. Foods high in fiber include grains, fruits and beans.

Discharge from hospital is generally the same day. Slowly increase your activities. Do not lift of do any strenuous activity for 3-5 days. Returning to normal activities takes around 7 to 10 days. However, if you have other health conditions, you may have a longer hospital stay or recovery at home and a longer recovery period.

Wound Care.

Do not soak in a bathtub until your steri-strips fall off (7-10 days) and your wound has healed. It’s OK to take a shower unless your surgeon tells you not to.

Biopsy

After the procedure, the gallbladder is sent for biopsy to confirm the diagnosis of either cholelithiasis or cholecystitis. The biopsy also helps to detect cancer. If cancer is detected, the patient might need to undergo another surgery to remove part of the liver or lymph nodes that are affected.

When to Call Your Surgeon

When you are discharged the nurses will tell you when to make an appointment for follow-up with your surgeon. Stitches or staples will be removed at follow-up. If you think you have a fever, take your temperature.

Prognosis

A small number of people are affected with post cholecystectomy syndrome, which has symptoms like gastrointestinal distress and/or constant pain in the right upper quadrant of the abdomen. Some others can develop chronic diarrhea after surgery. This can happen since the surgery causes disturbances in the bile duct. Most of the time no treatment is needed and clears up on its own within a few weeks. Many people have no symptoms at all after having their gallbladder removed.