Enhanced Recovery After Surgery

After our Outpatient Clinic visit, you will be scheduled for surgery. One of the best preparations to get ready for surgery is to learn as much as you can about your surgery. As you read through this web page, write down any questions you have to ask your surgeon or nurse at your next appointment.

1. What is Enhanced Recovery After Surgery (ERAS)? What does it mean for me?

Enhanced Recovery After Surgery (ERAS) is a system of treatments that helps you to recover from surgery faster. You will get out of bed soon after surgery and start eating and drinking. You will also get a better combination of pain medication that will help manage your pain. This will help you return home sooner and feel better faster.

There are no added risks to using an ERAS approach, so you can be confident that you are getting the best care possible with ERAS.

(Intermountain Healthcare, 2014).

Start by watching this video on Enhanced Recovery.

 

Your Surgical Journey

*Clicking one of these headers will slide down to the appropriate section*

Part 1: Your Bowels - A Review

  • What is a laparoscopic vs open surgery?
  • What is an Ostomy/Stoma?

Part 2: Before Your Surgery

  • Pre-Admission Clinic: You will meet with a nurse and anesthesiologist about your surgery.
  • What to do to prepare for your surgery at home?

Part 3: The Day of Your Surgery

  • What to bring to the hospital the day of your surgery
  • Surgical daycare: You will meet with a nurse, anesthesiologist and general surgeon before entering the operating room.
  • What will happen during my surgery?
  • Recovery room: you wake up from surgery and a nurse monitors you before moving to the general surgery unit.

Part 4: After Your Surgery

  • During the consistent care of a nurse, you will work with the physiotherapist and dietitian to enhance your recovery.
  • When it is time to go home?
  • How to make healing faster?

Part 5: Discharge and Going Home

  • When will my next appointment be?
  • What can I expect when I go home?
  • When and why should I need to see a doctor?

 

Part 1: Your Bowels - A Quick Review

2. Your Bowels - A Quick Review

You are going to have surgery on a portion of your bowels. The bowel is a tube that starts at the stomach and ends at the anus. It is where you digest all your food and eliminate stool or feces. You can learn more about your bowels on page 9 in your “Bowel Surgery - Your Guide to Recovery” information booklet or by talking to your surgeon.

There are two different ways that surgeries are done. Your surgeon will talk to you about which way your surgery will be done. Go to page 10 of your “Bowel Surgery - Your Guide to Recovery” information booklet to read more about bowel surgery.

1. Laparoscopic Surgery

  • Several small cuts are made on the belly
  • Surgery tools and a camera are inserted through the incisions

2. Open Surgery

  • A single, larger cut is made in the middle of your belly

Images retrieved from Eisenhower Medical Center at https://www.emc.org/info-center/?abcpdqxyz=79648595&action=detail&source=511&issue=577&dataRef=191&template=basic

Your surgeon might decide that you will need an ostomy (also called a stoma). Sometimes, it is not possible to reconnect the ends of the bowel. If this is the case, a piece of bowel is connected to an opening in your belly. This opening is called an ostomy or stoma. This means that stool will drain out of the opening on the belly into a bag attached to the belly. An ostomy can be temporary or permanent. Your surgeon will talk to you more about this. If you know you will be having an ostomy/stoma, please visit this website to learn more about ostomies.

To learn more about how to care for your stoma after your surgery, visit this website.

 

Part 2: Before Your Surgery:

3. Pre-Admission Clinic

The pre-admission clinic is where you meet a nurse to help guide you through the process of surgery, to go over what you need to do to get ready for surgery and answer any questions you may have. The appointment can last anywhere from an hour to one and a half hours.

Location:

The pre-admission clinic (or PAC) is located on the 3rd floor of St. Paul’s Hospital, Burrard Building. Enter through the Burrard street entrance, and take the elevators up to the third floor. Once you get off the elevators, turn right, walk to the end of the hall. You will see the pre-admission clinic on your right.

What to expect:

  • A nurse will ask you questions about your health history.
  • A nurse will tell you what medication you need to keep taking and what you need to stop taking.
  • You will meet with an anesthesiologist, a physician, who will put you to sleep during the surgery.
  • You will have some blood tests. You may also go for some other procedures (X-ray or ECG).
  • If you are going to have an ostomy/stoma, you will meet with the Ostomy Nurse. Your surgeon will tell you if you need an ostomy or not.

What to bring with you to this appointment:

All your medications, supplements, and herbal products in their original containers. You learn a lot of information at this visit, so bring a family member or friend with you.

Screenshot of “Patient Education Video- Enhanced Recovery” retrieved from https://www.youtube.com/watch?v=swXJ_7Gtqz4

4. Preparing for your surgery at home

There are steps to take to get yourself ready for surgery. It is important to be as healthy as possible before your surgery. You should do the following:

  • Stop smoking at least one month (or as soon as possible) before surgery.
    • If you need help quitting, you can get free nicotine patches or gum by calling 8-1-1 and registering for the BC Smoking Cessation Program. Visit the QuitNow website for more help at www.quitnow.ca
  • No alcohol for at least 48 hours before your surgery.
  • Exercise helps you to be in the best shape possible before surgery. Do some light exercise for about 30 minutes each day. For example, go for a walk or do some stretching.
  • Plan your return home. For example:
    • Where will you be going after you leave the hospital? Home or with family or friends?
    • Who will drive you home from the hospital?
    • How will you prepare your meals after you get home? Prepare and freeze meals ahead of time so all you have to do is reheat. Shop for extra food that is easy to prepare after you get home.

 

           

Retrieved from http://www.houstontx.gov/health/Environmental/smokingpage.html

 Retrieved from https://myhealth.alberta.ca/Learning/ERAS/Pages/Section2A.aspx

5. The night before your surgery:

There are several preparations the night before surgery to get yourself ready. Look at pages 15 to 19 of your “Bowel Surgery - Your Guide to Recovery” booklet for more information.

 

Part 3: The Day of Your Surgery:

6. The morning of your surgery

You will need to bring some belongings to the hospital. Make sure your bag is labeled with your name. Follow this checklist to make sure you bring everything you need:

  • Your BC Services Card / CareCard and your private insurance information
  • Your Driver’s License or other government-issued identification
  • All of your medications in their original containers (including non-prescription medication)
  • Your copy of the “Bowel Surgery: Your Guide to Recovery” manual.
  • Sugar-free chewing gum for after surgery
  • Housecoat or pyjamas, and slippers with non-slip soles
  • Toothbrush, toothpaste, soap, deodorant, shaving equipment, ear plugs
  • Comfortable clothes to wear on the day of going home
  • Glasses (in the case with your name on it)
  • Dentures and the container labelled with your name
  • Hearing aids and spare batteries (with the container labelled with your name)
  • Mobility aids you normally use (such as a cane or a walker)

 

Why should I bring sugar-free chewing gum?

Chewing sugar-free gum is an important part of recovery. After surgery, it is normal for your bowels to move slower than normal. Research has shown that chewing sugar-free gum several times a day for 30 to 60 minutes will help your bowels to “wake up” faster.

 

 

Retrieved from:http://www.womenshealthmag.com/health/chewing-gum

7. Surgical Daycare

Surgical daycare is where you will check in and be prepared for surgery.

Directions:

Surgical Daycare at St. Paul’s Hospital is located on the 3rd floor of the Providence Building. For directions, follow this link.

What to expect:

  • You will check into reception and change into a special hospital gown called a “Bair Hugger” to keep you warm.
  • A nurse will ask you some questions before your surgery to make sure your preparation is complete.
  • You will receive wipes to cleanse your skin.
  • You will get an intravenous (IV) put into your arm to receive medications and fluids throughout your surgery.

You can keep your dentures, glasses, and hearing aid(s) on until you are asked to take them off. Give your bag of clothes or belongings to a family member, and they can give the bag back to you after your surgery.

You will get some pain medication and some medication to prevent blood clots. You may have an epidural based on the type of surgery you are having. An epidural is a small tube that the anesthesiologist inserts into your back to give you pain medication.

Screenshot of “Patient Education Video- Enhanced Recovery” retrieved from https://www.youtube.com/watch?v=swXJ_7Gtqz4

8. Operating Room           

Once you are lying down on the bed in the operating room, you will be given medication to help you fall asleep. You will also be given an oxygen mask to breathe through as you fall asleep.

Once you are asleep, the anesthesiologist will put a tube down your throat in order to help you breathe while you are asleep. The tube will be removed before you wake up, but you might have a sore throat for 1 to 2 days.

The nurse will insert a urinary catheter to monitor your urine output during surgery. The catheter will typically be removed before you wake up from surgery. In some cases, the catheter will need to remain in place for a few days, depending on the type of surgery you had.

Sometimes, a surgical drain is needed to remove extra fluid from the surgical site. The drain will be removed when there is no more fluid.

Screenshot of “Patient Education Video- Enhanced Recovery” retrieved from https://www.youtube.com/watch?v=swXJ_7Gtqz4

9. Post-anesthesia recovery room

Once your surgery is over, you will be moved to the “Post-Anesthetic Care Room” (PACU), which is also called the recovery room.

When you wake up, you should expect to see these things:

  • An intravenous or IV.
  • An epidural (if your surgery required one)
  • An ostomy/stoma (if your surgery required one)
  • A urinary catheter (if it was not removed during the surgery)
  • An oxygen mask

You will wake up here, but you will feel very drowsy from the sleep medication you received throughout surgery. The nurse will help you to put your glasses and hearing aid(s) back on. You will have a mask over your mouth that is giving you oxygen. You will have an intravenous (IV).

In the recovery room, a nurse will check your blood pressure, pulse, and breathing rate quite frequently. The nurse will also be checking your bandage covering your surgery area. You might start feeling pain, and you will get pain medication.

Once you are stable, someone will move you to the post-surgical nursing unit. You will stay there for several days to recover. Once you are comfortable on the unit, your friends and family can visit you.     

High Acuity Unit (HAU): In some cases, some people need to be monitored for a little bit longer. If you have multiple health conditions or depending on the type of surgery you had, you might have to go to the High Acuity Unit first before going up to the surgical nursing unit. You may stay here from a few hours to several days.

Screenshot of “Patient Education Video- Enhanced Recovery” retrieved from https://www.youtube.com/watch?v=swXJ_7Gtqz4

 

Part 4: After Your Surgery

10. Post-surgical unit hospital stay

After the recovery room (or HAU), you will stay in the surgical unit until you are ready to leave the hospital. On this unit, the nurses will work with you to control your pain, increase your activity, return to eating, and prevent complications. Your length of stay will depend on when you meet the criteria for going home. In order to meet the criteria to go home, you will need to actively participate in your recovery. The average stay on this unit is 3 to 5 days.

The criteria mentioned above includes:

  • €You are able to manage your pain using pills only.
  • You are able to eat without feeling pain or bloating.
  • You are passing gas or have had a bowel movement.
  • You are able to do most of your activities to manage self-care at home.
  • There are no signs of any problems from your surgery.
  • If you have an ostomy/stoma: you can look after your stoma on your own, change your bag and appliance, and know how and when to order supplies.

Screenshot of “Patient Education Video- Enhanced Recovery” retrieved from https://www.youtube.com/watch?v=swXJ_7Gtqz4

Pain

Feeling some pain after surgery is normal. Some people might avoid taking pain medication because of fear of addiction. Others think they should just “grin and bear it”. It is important to know that you will not become addicted to pain medication after surgery. You will need to manage your pain as you become more comfortable. You can reduce the dose and/or frequency of your pain medication. When your pain is controlled, you will be able to perform your recovery exercises more often.

You may have been prescribed a PCA or “patient controlled analgesia”. The PCA is a pump that allows you to receive pain medication by pushing a button. The pump contains a syringe with this medication that is connected to your IV. The pump will only give you what has been prescribed so you will not have to worry about receiving too much. If it is too little and you still feel pain, let the nurse know.

There are other ways you can control your pain. After taking your pain medication, try some of these techniques:

  • Do slow and deep breathing
  • Listen to music
  • Imagine peaceful situations or meditate
  • Ask for a warm blanket

Pain Score

You need to be able to tell the nurse exactly how much pain you have. To help the nurse assess and manage your pain, we use a pain rating scale. The scale starts at 0 (meaning no pain), and goes up to 10 (meaning the worst pain possible). You score your pain between 0 and 10. Let your nurse know if your pain reaches level 4 or higher, or past your comfort level.

Pain-Scale2--Arvin61r58-800px.png

Pain assessment tool retrieved from https://openclipart.org/detail/238112/pain-scale-fixed

Nausea and Vomiting

You might feel sick to your stomach (nausea) or throw up (vomit) once your surgery is over. It is important to manage your nausea in order to help you eat as soon as possible. For the first 24 hours after your surgery, you will receive anti-nausea medication regularly. Tell the nurse as soon as you start feeling sick to your stomach, so that you can be treated right away. This will help to stop your nausea from getting worse.

As possible, try these tips to settle your stomach:

  • Take some slow, deep breaths.
  • Ask for a cool, damp cloth to put on your forehead.
  • Try distracting yourself by listening to music or watching TV.
  • Take small sips of water or suck on some ice chips.
  • Chew sugar-free gum.

Eating, drinking, and digestion

You will need lots of healthy food to help you heal. After surgery, your bowels will move slower than normal. You can help your bowels return to their normal speed by drinking and eating as soon as you can. You will meet with a dietitian to talk about your diet plan. At first, you will be on a fluid diet. Once you start passing gas, you will start eating solid food.

A nurse will often ask you if you are passing gas. This is a sign that your bowels are waking up after your surgery. The best way to help your bowels wake up is to get up and walk. You should also chew sugar-free gum several times a day, for 30 to 60 minutes each time.

Activity

You will heal and go home faster as soon as you can get up and start moving around. If you spend all day lying in bed, you can get muscle weakness, blood clots, or other complications. After your surgery, you will meet with a physiotherapist who will give you an activity schedule and help you with your exercises.

A nurse or physiotherapist will help you to start moving the day of your surgery. Most people are up and walking the day after surgery with assistance. Each day, you will gain more strength and be more active. It is important to keep activity short and frequent and take breaks in between activities. Remember to take your pain medication to help you do your activities.

Moving around in bed

When you are in bed, you will have to move and change your position at least every 2 hours. There are exercises that you can do while lying in bed. Instructions for these exercises can be found on page 26 of your “Bowel Surgery - Your Guide to Recovery” information booklet.

Leg exercise

Every day after surgery, you need to do leg exercises to keep your muscles strong, prevent blood clots, and keep your joints from becoming stiff. You can learn how to do the four leg exercises on page 27 of your “Bowel Surgery - Your Guide to Recovery” information booklet. Do these exercises every hour while you are in bed.

ankle exercises 1.png

leg exercises 1.png

Images retrieved from Providence Health Care’s “Bowel Surgery - Your Guide to Recovery” patient booklet.

Deep breathing and coughing

Deep breathing and coughing exercises done hourly will help you to breathe better and prevent a lung infection. Please remember to do them every hour on your own. The nurse and physiotherapist can help you practice these exercises. For instructions on how to do deep breathing and coughing exercises, go to page 25 of your “Bowel Surgery - Your Guide to Recovery” information booklet.

Watch this video on deep breathing and coughing (the YouTube link will take you to the exact spot in the video that discusses deep breathing and coughing exercises).

Important to note:

  • When you are coughing, support your incision with a small pillow or blanket.
  • Ask a nurse if you are able to take any pain medication before starting your exercises.
  • It is important to purse your lips when exhaling so you completely empty your lungs.

Deep Breathing and Coughing 1.pngDeep Breathing and Coughing 2.png

Images retrieved from Providence Health Care’s “Bowel Surgery - Your Guide to Recovery” patient booklet.

Screenshot of “Patient Education Video- Enhanced Recovery” retrieved from https://www.youtube.com/watch?v=swXJ_7Gtqz4

What to expect each day:

Click on image below to Download PDF

Part 5: Discharge and Going Home

11. Discharge and going home

With most surgeries, people are able to go home 3 to 5 days after their surgery day. We will know you are ready to go home when you meet these 5 criteria:

  • €You are able to manage your pain using pills only.
  • You are able to eat without feeling pain or bloating.
  • You are passing gas or have had a bowel movement.
  • You are able to do most of your activities to manage self-care at home.
  • There are no signs of any problems from your surgery.
  • If you have an ostomy/stoma: you can look after your ostomy/stoma on your own, change your bag and appliance, and know how and when to order supplies.

12. Caring for yourself at home

Once you are home, you will still not be ready to go back to your normal life before surgery. It might take you several months before you feel completely recovered. There are many recommendations to help you recovery quickly. You will manage your pain with less medication, increase your diet as your appetite gets better, and gradually increase your physical activity. You will also need to manage your incision and your ostomy/stoma (if you have one). Your incision should be clean, dry, sealed, and less painful. It should not be swollen, red, hot to touch or more painful. For details on how to take care of yourself after you are home, see pages 40-44 in your “Bowel Surgery - Your Guide to Recovery” information booklet.

This is how your incision should look whether you have sutures, steri-strips or staples

http://www.vanderbilthealth.com/includes/healthtopics/quizzes.php?ContentTypeId=3&ContentId=89313&Category=Quizzes&SubtopicId=8186&section=quizzes

Screenshot of “Patient Education Video- Enhanced Recovery” retrieved from https://www.youtube.com/watch?v=swXJ_7Gtqz4

13. Follow-up appointments

Normally, you will meet with your surgeon 2 or 3 weeks after you go home for a follow-up appointment. The surgeon will see how you are recovering, talk to you about results from your surgery, and discuss any other treatments you may need. You will receive instructions on how to organize a follow-up appointment. The hospital does not make the appointment for you, so it is important you make the call yourself.

Contact your surgeon or family doctor if:

  • Pain persists or gets worse even if you take pain medication.
  • You have a fever of greater than 38.5o C (101.3o F)
  • Your incision becomes red, swollen, or hot to touch.
  • You notice foul smelling liquid coming from your incision.
  • You start bleeding from your incision.
  • You feel sick to your stomach (nausea) or throw up (vomiting) often for more than 24 hours.
  • You have diarrhea that lasts for more than 2 days.
  • You have a drain that is accidentally pulled out.

For more information, call HealthLink BC at 8-1-1 to talk to a registered nurse, dietitian or pharmacist. (Link to HealthLink BC: http://www.healthlinkbc.ca/)

Screenshot of “Patient Education Video- Enhanced Recovery” retrieved from https://www.youtube.com/watch?v=swXJ_7Gtqz4

14. Closing Statement

Surgery isn’t easy. But with Enhanced Recovery, you can take more control over your health. You can get back to doing what you love faster and safer. Remember: you can do this!

Image References

“Minimally invasive surgery” and “Open surgery” (Images). Retrieved from https://www.emc.org/info-center/?abcpdqxyz=79648595&action=detail&source=511&issue=577&dataRef=191&template=basic

“No smoking” (Image). Retrieved from http://www.houstontx.gov/health/Environmental/smokingpage.html

“Exercise” (Image). Retrieved from https://myhealth.alberta.ca/Learning/ERAS/Pages/Section2A.aspx

Screenshot of “Patient Education Video- Enhanced Recovery” retrieved from https://www.youtube.com/watch?v=swXJ_7Gtqz4

“Sugar free gum” (Image). Retrieved from: http://www.womenshealthmag.com/health/chewing-gum

“Pain assessment tool” (Image). Retrieved from https://openclipart.org/detail/238112/pain-scale-fixed

“Incisions” (Image). Retrieved from http://www.vanderbilthealth.com/includes/healthtopics/quizzes.php?ContentTypeId=3&ContentId=89313&Category=Quizzes&SubtopicId=8186&section=quizzes

BC Enhanced Recovery Collaborative. (2016). Screenshots of “Patient Education Video- Enhanced Recovery” retrieved from https://www.youtube.com/watch?v=swXJ_7Gtqz4

Providence Health Care (2013). Images from “Bowel Surgery - Your Guide to Recovery” Patient Information Booklet.