The PreOp-Guide
A Patient's Guide To Surgery
Chapter 4
Outpatient Surgery
     If you are scheduled for an outpatient surgery, you are among the first in what will assuredly prove to be the wave of the future.  Although outpatient minor surgery has been performed for decades, it is only in the past few years that major operations are being performed on an outpatient basis.  There is much rationale for outpatient surgery, but the truth of the matter is that it is less expensive to perform surgery outside of the hospital.  Outpatient surgery can be performed at a stand-alone institution that does not have the expense of 24-hour nursing staffs, food preparation and delivery services, radiology departments, physical and occupational therapy departments, social workers, and more.  Yet, because it is less expensive, does not mean it is of lesser quality.  As the focus of surgery has shifted to outpatient procedures, many benefits to patients have been noted.  For one, surgery is more affordable, and people who once were not able to have needed surgery because of monetary considerations are finding themselves able to have needed operations.  Many of the indignities of hospitalization can also be avoided.  It is nice to be able to show up for surgery in comfortable clothing, and to leave the same day in that same outfit with your operation behind you.  No one will ever wake you up in the middle of the night after surgery to take your pulse, temperature, and blood pressure; yet this happens to every single patient who spends the night in a hospital.  The food at home, even if it is take-out, is probably better than the meal your unfortunate hospitalized neighbor is eating; and your own bed is more comfortable than any hospital bed I have ever seen.  Finally, and perhaps most importantly, the outpatient surgical revolution has forced surgeons to rethink the way they perform their operations.  Less painful, less invasive techniques have been developed, and recovery from surgery has improved dramatically in response to these changes.  Improvements in oral pain medications have also allowed patients to remain as comfortable at home as those receiving intravenous medication in the hospital.

     Don’t forget to bring your completed PreOp-Worksheet when you leave for the hospital or surgery center.  Although you are staying for only a few hours, several people will need the information you have collected, so having it will speed your admission and interview process.  Also, people who are initially scheduled for outpatient surgery sometimes require hospital admission, and if this happens to you, you will want the information on the worksheet available to you and your physician.  When you arrive at the hospital or surgery center for your outpatient operation, expect to fill out some paperwork.  Once you have registered, you will be directed to a waiting room filled with other surgical patients, as well as their families and friends.  As the time comes for your operation to begin, you will be asked to change into a hospital gown, and you will probably be given a locker to store your belongings.  You will then be taken to the preoperative area where you may need to have some blood drawn and an intravenous line will be started.  A person from the anesthesia department and/or a nurse will interview you to make sure you are ready for the operation; and if all is in order, you will be taken to the operating room.  

     There are several things to keep in mind when you arrive for your procedure.  The first is that the admitting staff does not bear any responsibility for the delays you may possibly face.  Just as with inpatient surgery, surgeons schedule cases to follow one another, and unless you are the first case of the day, it is highly likely that your operation will not begin precisely at the time scheduled.  When planning operative schedules, operating room personnel allocate a standard amount of time for each type of operation.  The law of averages holds that in half of the cases it will take less than that amount of time to complete the operation, and half of the time it will take longer.  Therefore, be prepared to have you operation occur hours earlier or later than scheduled.  On occasion, operations are also canceled, opening holes in the OR schedule.  In order to make the most efficient use of operating room time, you may be asked to come in early for your surgery.  Remember also that in most communities surgeons are a scarce commodity; and unfortunately, emergency situations arise every day that require the unique skills of a surgeon.  If you are unlucky enough to have your elective surgery scheduled at the same time that a person develops appendicitis or a major auto accident occurs, you may find that your case is postponed for hours or perhaps canceled outright.  This can be a frustrating experience, but remember that if the emergency were happening to you or one of your family members, you would want immediate life-saving attention of a surgeon. Second, there is a fair amount of lag time between when you leave for the operating room and when the operation actually begins.  You will have to be properly positioned on the operating table (a very important step to avoid complications), surgical instruments and monitors will be applied to your body, anesthesia will be administered, and a skin sterilizing procedure will be performed before the surgeon may begin the operation.  Problems or delays with one or more of these very routine events can occur for a number of reasons.  Optimal surgical care requires perfect integration of services provided by numerous, and a problem in any phase of this care can lead to frustrating delays, but again, perfection is the only option when performing surgery.

     All of the care you receive up to this point is similar to what you would experience were you to have inpatient surgery.  The real difference in outpatient surgery is noticed after completion of the operation.  You will likely find yourself in a recovery room after surgery, and depending upon the type of operation performed, you may be lying on a stretcher or sitting up in a chair.  Outpatient surgery utilizes numerous types of anesthesia, and the type chosen for your particular case will determine how your recovery progresses.  If you had only local anesthesia with mild sedation, you will be monitored for a brief period of time, and then allowed to go home.  Before you leave, your medical condition will be assessed, and you will be given instructions on what to expect and when to follow up with your surgeon.  You may also be given a prescription for pain medication, antibiotics, or other medications your surgeon feels you will need in the recovery period.  In almost all cases you will not be released from the center until someone comes to pick you up.  In circumstances where no one is available to bring you home, expect to spend several hours in the recovery room until the effects of the anesthetic have completely worn off.  My suggestion is that you make sure you will be picked up after surgery.  You can then be driven home, climb into bed, and relax and sleep while the residual effects of the anesthesia wear off.  You will then also have someone who can take you to the pharmacy to pick up your needed medications, as well as monitor you for any problems associated with your operation.  In a worst case scenario, you will have someone there to take you back to the surgery center, your doctor’s office, or an emergency room should a complication develop.

     The recovery period for patients who required deep sedation, general anesthesia, or a regional or spinal/epidural anesthesia is not much different from that outlined above, with the exception that a longer period of observation follows the procedure.  Depending upon the operation, you can also expect to have to pass one or more simple tests before being released.  For example, a common problem after hemorrhoid and hernia surgery is the inability to urinate, particularly in men.  This is due to stimulation of nerves in the vicinity of the urinary bladder in combination with bladder distention (the filling or overfilling of the bladder).  The solution to this problem is simple, but requires the intervention of a nurse or physician; therefore, you will not be allowed to leave the hospital after these surgeries until you have demonstrated your ability to urinate.  

     If your surgery involved the placement of a drain or the application of a complicated surgical dressing, you will need training and instruction on how to care for yourself at home.  It is nice to have a friend or family member (who, by the way, did not just have anesthesia) receive the training with you.  That way, there will be a resource at home should questions arise.  You may also require training on the use of crutches, traction devices, or splints after your surgery.  Most surgeons will go over your postoperative instructions with you prior to the procedure and give you a written set of instructions when you leave.  A technique I find very useful is to provide instructions and prescriptions for all of the postoperative medications several days in advance of the surgery.  This way the patient has the opportunity to ask questions and fill prescriptions before hand, thus having the medication available immediately after surgery.  If your surgeon doesn’t offer this option, ask about it.  Maybe your doctor will consider trying something new.

     When you get home, the best thing to do is go to bed.  There are very few anesthetic agents that are so short acting that all of their effects are gone within hours of surgery.  Therefore, you will probably not be functioning at full mental capacity after surgery.  A few good hours of sleep will enable your body to rid itself of the remaining anesthesia and will let you sleep off the onset of the postoperative pain.  If your surgery was on an extremity (i.e., arm, leg), it is usually a good idea to elevate that extremity to prevent the development of swelling.  Some surgeons will also recommend the application of ice or warm packs to the surgical site (ask your surgeon for the specific type of wound care he or she prefers for your individual operation).  

     Pain is a common theme postoperatively, and as I stated before, you should think of surgery as a controlled injury.  Pain at a surgical site (sometimes even severe pain) is not unusual.  Do not hesitate to take the pain medicine prescribed by your surgeon.  Many people worry unnecessarily that by taking pain medication (particularly those medications containing narcotics) that they will become “addicted” to them.  This concept is completely false and there is plenty of good scientific evidence that people who take narcotics or other pain killers to control postoperative pain do not become addicted to the medications.  In fact, the best way to control your pain and ensure a swift recovery is to take the painkillers before your pain becomes severe.  The medication you are given will attain a certain level after every dose you take.  When the medications are taken on a regular schedule, the level of painkiller will not reach zero before the next dose is given, thereby establishing a baseline drug level in your body.  This prevents the development of severe pain, thus reducing the need for higher doses of medication.  On the other hand, if you take your pain medication only when you are in severe pain, you will require a much higher dose to control your discomfort because no level has built up in your body.  This leads to future episodes of pain, which again require high doses of pain medicine to alleviate.   With this in mind, my suggestion is that you begin by taking the dose of the pain medicine prescribed at the shortest time interval allowed.  If after several doses of the medication you remain comfortable, slowly begin to increase the interval between doses.  Once you are able to tolerate the increased dose interval comfortably, you may begin to decrease the dose of the medication you are taking (i.e., from 2 pills to1 pill, perhaps even to ½ pill).  At some point you will be able to stop taking the medication all together, although you may find that you will need 1 pill after particularly strenuous activity or when going to bed.  When a week has gone by with no need for the medication, safely throw the remainder away.  This will prevent the temptation to take the pills after a bad day or a “minor” injury for which you do not seek medical attention; it also prevents the medication from falling into someone else’s hands or being accidentally ingested.

     There are several common after effects of surgery that you should be aware of.  An obvious one is your impaired mental capacity and judgment immediately postoperative and while you are taking pain medication.  Do not plan to make any important legal, business, or personal decisions in the early postoperative period.  This probably means you will need to take a few or more days off from work after your operation.  This is something you should discuss with your surgeon before the operation and let your friends, family, and employer know beforehand.  Invariably some patients feel the need to return to work or hobbies the day after (or sometimes the day of) surgery, I strongly advise against this.  If you need an operation, you deserve a day off as well.  Another thing many people experience is nausea, vomiting, or lack of appetite.  This is usually a side effect of the anesthesia or the pain medication you have been given.  If this happens, continue to drink plenty of liquids, preferably those without caffeine, and certainly avoid any beverages containing alcohol.  If the nausea and particularly if vomiting does not resolve within 24 hours of your operation, call your surgeon and let him/her know what is going on.  You may find that a new type of painkiller is prescribed, or depending upon your symptoms your surgeon may ask you to come in for a quick check up.  Loss of appetite usually resolves itself within a few days. If it doesn’t, you should mention it to your surgeon at the time of your first follow-up visit.

Another issue to be discussed is constipation.  Narcotic painkillers can be very constipating, and in combination with decreased appetite and poor fluid intake, a small constipation problem can quickly turn into a difficult situation to manage.  For this reason, many surgeons will put you on a high fiber diet or recommend that you take Metamucil, Citrucel, or some other similar product for a week or two postoperatively.  Given that the average American eats a diet low in insoluble fiber to begin with, this is a good recommendation to follow.  Another safe and inexpensive medication that you can buy over the counter is the stool softener Colace (doccusate sodium).  If you have trouble locating this in the drug store, ask your local pharmacist for a stool softener.  Follow the directions on the label, and you will find that you bowel movements will not be as hard or difficult to pass.  Beyond this, there are a thousand over-the-counter medications and home remedies for constipation.  For patients on non-restricted diets, I suggest Milk of Magnesia, which is available under several different brand and generic names.  Patients with renal failure or electrolyte imbalances should avoid these medications, and once again ask your surgeon or pharmacist for recommendations that suit your particular medical condition.  Constipation is a problem best treated before it develops, and if you faithfully take these medications while on narcotic analgesics, you should have no problems.  If, however, you find yourself having fewer bowel movements after your surgery than you did before surgery, let your surgeon know sooner rather than later. You’ll both be glad you did.

     The final issue in this chapter pertains to postoperative problems that require immediate medical re-evaluation.  The problems I will discuss would have been picked up immediately had you remained hospitalized.  They are infrequent occurrences, but since you will be recovering at home, you need to recognize these problems early so they can be dealt with swiftly.  

     The first category is hemorrhage, or blood loss.  You probably have a surgical dressing that covers the area of the incision.  It is normal for this dressing to become damp with a yellow to pink fluid.  In some cases, you may even see a circle of blood develop, which is a dark red to nearly black.  Don’t worry about these developments, they represent a trivial blood loss which will spontaneously resolve.  If, however, the dressing becomes saturated with bright red blood or if the skin under the dressing begins to swell rapidly and appears obviously elevated (relative to the skin around it), you probably have a small bleeding vessel which can often be fixed simply with pressure or the placement of a stitch.  In these cases, apply pressure directly over the wound and call your surgeon.  You may be instructed to remove your dressing and re-apply a fresh one, or your surgeon may want to have someone in his or her office take a look at it.  In either case, this does not constitute an emergency, but it should be addressed promptly.  If you begin to feel lightheaded or short of breath, or if it feels like your heart is beating rapidly, you may have lost a more significant amount of blood.  In this case, you should take your pulse by placing your index finger on your neck just below the corner of your jawbone (below your ear).  Using a watch or clock with a second hand, count the number of pulses you feel in 60 seconds.  This is your heart rate, and if it is over 100, you should inform your surgeon.  If you or one of your friends or family has an automatic blood pressure machine, or if you know someone trained in taking blood pressures, have this number available for your surgeon as well.  A rapid heart rate in conjunction with a low blood pressure is a worrisome thing.  An additional way to assess if you have lost too much blood is to measure your output of urine.  If you find that you have not had to go to the bathroom for an abnormally long period of time, this too is troublesome.

     Another possible problem in the immediate postoperative period is infection.  You should take your temperature at home if you feel at all hot or uncomfortable.  A slight temperature is normal after anesthesia and surgery, so any temperature below 100.4 degrees Fahrenheit (38 degrees Celsius) is nothing to worry about.  Temperatures over 102 degrees Fahrenheit (39 degrees Celsius) begin to be of concern, and should be reported.  Temperatures between these marks (100.4 – 102 F) are probably not important, but you should take a look at the operative site and dressing to see if there are other signs of infection.  The most important finding suggestive of infection is redness.  If the area around your incision (or your dressing, if you have one on) is hot and red, this is indicative of an infection and your surgeon should be informed.  A small margin of redness is OK, but it should not extend more than half an inch from any part of the wound.  Other findings that are suggestive of infection include tan drainage from the wound, and a foul smell from the wound.  If you notice either of these, especially in association with a fever, let your surgeon know immediately.  Finally, and most unusually, some infections spread rapidly and need immediate treatment, usually with intravenous antibiotics.  If you notice red streaks extending away from your incision, or if you feel bubbles of air under your skin (it feels like pressing on a pile of Rice Krispies, and sounds like the snap, crackle, pop of milk going over the same cereal), you need to get to an emergency room as soon as possible.

     If you have any of the problems described above, and you feel uncomfortable about your situation, call your surgeon.  Even if you have the feeling that something is wrong, but you can’t quite put your finger on it, you should let someone know.  Remember that you no longer have a trained medical professional looking after you, and if you have any problem or concern about your procedure or recovery, you should contact your surgeon for an answer.  Most surgeries occur without any problems, and most recoveries are uneventful and routine, but with outpatient surgery becoming more and more popular, there are bound to be occasional complications.  When addressed in a timely manner, almost all complications can be quickly resolved and have no long-term consequences; however, small problems which are ignored can rapidly turn into life-threatening situations.  The basic rule of thumb for those of you who have outpatient surgery should be: “If you are not sure if there is a problem, ask you surgeon.”

Chapter 2
Chapter 3
Chapter 1
Chapter 4
Chapter 5
Chapter 6
Chapter 8
Chapter 9
Chapter 10
Chapter 11