Discomfort and special care after surgery (still in the hospital)

 

Usually, you will stay hospitalized for 2 nights after the surgery. In some cases, more days might be required.

Pain: It is possible that you feel pain in one or both shoulders and/or your back; it does not apply to every patient though. This is caused by your diaphragm’s distension during the laparoscopic procedure. This distension stimulates the phrenic nerve, which is interpreted by the brain as pain but cannot recognize its diaphragmatic origin: the shoulder area. This is known as referred pain, or reflexive pain, and it will disappear within a few days. The more active you are, the faster the gas will leave your abdomen, making the pain go away faster. It is possible that you also feel some pain in the small incisions in your abdomen. When you are discharged, you will be given a prescription for painkillers with detailed instructions.

After surgery, you must start walking, even if it is painful, because it is the best thing you can do and it will barely be uncomfortable afterwards.

Walking helps reduce reflex pain, decreases risk of blood cloths (thrombus) and other complications. It is so important to do itas much as you can. If you are in too much pain, please let us know so that we can give you some painkillers.

Pain intensity varies from patient to patient and so does pain medication effect. Do not worry too much about pain, most of the patients refer discrete discomfort during the first 24 hours, some others refer no pain at all and very few have had a more intense pain. Depending on how intense the pain is, we are going to give you certain types of analgesics (most of the time we will give you acetaminophen, ketorolac, or tramadol) or a more powerful medication such as morphine if you are in severe pain.

Again, remember that what will help you the most is walking, so we need your cooperation in order to reestablish bowl movements and help to eliminate gas trapped in your bowl and abdomen.

Intestinal Gas and Abdominal Distension: You may experience belching, flatulence or bloating after surgery. This is caused by organ manipulation, medication administered, and some maneuvers done during surgery that increases intra-gastric gas. Since your stomach is smaller after surgery, sensibility to gas changes and a small quantity of gas may be felt as a huge amount. Distension of your new small stomach may cause a reflex pain that can be felt as oppression on your chest and shoulders.

Malaise: It is possible that you feel stunned, have bad taste in mouth and some nausea. To help decrease and eliminate these symptoms, it is important you start moving as soon as possible and not lying on the bed all the time. Wash your teeth or use mouthwash for the bad taste after the surgery.

Take a shower with warm water (or cold water if you prefer), this will help you feel better. You can take a bath either the next day after the surgery or on the same day of the surgery. Remember not to scrub or rub your incisions, just allow the water to flow down your abdomen and dry them without rubbing them.

Nausea is very common during the first 24 hours but it is easily managed with anti-emetic medication such as diphenidol or ondansetron.

 

Discomfort and Special Care after Surgery (When Discharged)

 

Abdominal distension: The main discomfort after discharge is abdominal distension or bloating. Because this is caused mostly by gas in your bowl, the best way to get rid of it is by walking, lying down on your right or left side or changing position frequently. In most cases, this will disappear within the first 48 hours.

Pain: In some rare cases, pain may last as long as three weeks and irradiate to your back, breasts, and shoulders. This must be controlled with painkillers. When pain lasts longer, it is frequently due to poor stomach and bowl gas elimination.

There are some things that you should do to reduce intra-abdominal gas, mainly during the first post-op month.

  • Do Not speak for long periods of time.
  • Do Not chew gum.
  • Do Not have drinks with a straw.
  • Do Not smoke or try to burp on purpose.
  • Try to eliminate gases when you evacuate. The more time you spend on the bathroom, the more gases you will be able to expel, which is a good thing.

 

Shower: It is best if you take a shower once a day because, at this point, you will have your incision gauzes changed. You should let water flow down your abdomen and dry them without rubbing. Do not take baths nor go swimming in pools or the ocean for two weeks after the surgery, so you help your incisions to heal correctly and to reduce infection risk.

Medication after the Surgery

  1. We will give you painkillers: our patients generally take them for no more than 4-5 days. Nonetheless, you might need them for two or more weeks. Most of the time, we prescribe Norflex Plus (1 tablet every 8 hours) for sleeve gastrectomy and gastric plication surgerires, for gastric bypass and mini gastric bypass we prefer to use tramadol (1 tablet every 8 hours). You can dilute the tablet in a little bit of water and drink it. If you do not experience pain, it is not necessary to take this medicine.
  2. We will prescribe you antibiotics that you should take from 5-7 days after the procedure. Patients that are not allergic to penicillin, we frequently prescribe a 2nd generation cephalosporin.
  3. You will also need to take an antacid (omeprazole, pantoprazole, lansoprazole) for at least 2 months after the surgery.
  4. We will also prescribe you nausea medication:Diphenidol is good enough. The truth is most patients will not need it.
  5. We will give you a pill that will help you to sleep better. Patients often ask for “something to sleep better”, you can take Benodrom (melatonin), a 5mg-pill or two 3mg-pill 15 minutes before going to bed. Extreme cases may require a better option: Tafil (alprazolam). Remember to let us know when you have trouble sleeping because you will need a prescription to buy it.
  6. Finally, every patient must take vitamins and minerals 1-2 tablets each morning for at least one year after a sleeve gastrectomy.

 

How should I take these drugs?

Remember that, after your surgery, you will not be able to take pills that are bigger than the size of a pencil’s eraser, unless it comes in a capsule presentation. Since the capsule can be dissolved in water, you can keep it into your mouth and then swallow it until the outer layer is softer. If the tablet is bigger than the size of a pencil’s eraser, you should crush it before swallowing it. Remember that you have a very small stomach now, so you might want to wait at least 30 minutes to lie down after taking your medication to avoid esophagus irritation or the feeling that something is “stuck”.

Incisions: All you need to do during the first week after the surgery is to keep your incisions dry and clean. If you notice your skin starts to get warmer and redder or starts to suppurate or a rash appears, please contact us right away (this might be a wound infection or contact dermatitis).

Two weeks after your surgery, you may apply creams or ointments for a better esthetic result of the small scars (some ointments we recommend are Mederma, Scarfade, E Vitamin, or any other medical treatment for scars). Remember that you need to wait weeks to start using them; before this time, it could cause the wound to open. Do not bath and do not go to pools or ocean swims for the first 15 days or until your wounds heal.

Drink Water and Stay Hydrated: It is very important to stay hydrated after your surgery. Your new small stomach will not allow the entry of great amounts of liquid at the same time, so you will have to learn to take small sips of water constantly to avoid dehydration. One of the most common causes of nausea and dizziness in the recovery period is dehydration. The classic symptoms of dehydration in the postoperative period are nausea, dizziness, weakness, and fatigue; other symptoms are dry mouth and concentrated urine in both color and odor. If you present any of these, increase your liquid ingestion nut if there is no improvement, contact us.

Diet: Remember you need to strictly follow your meal plan and avoid solid food for the first month. The first weeks there should not be any stomach distension, so we recommend that you take your meals with liquids.

It is crucial that you follow you liquid diet during the first month after the surgery to avoid complications

After the first month, you will be able to have purees and soft solid meals. Remember to take small bites and chew until the bite is correctly triturated. If you have trouble with a certain food, do not worry, you can try it again in a few days. It is normal that you have problems when swallowing and eating certain foods. It is a part of the process, especially during the first three months—you are most likely to be able to eat it later. Remember to drink lots of water during the day. Try carrying a bottle of water with you all the time.

Constipation: During the first month constipations is due to lack of solid food. After the first month the main reason for constipation after surgery is due to a lack of liquids. Tramadol or other painkillers can also cause constipation. So, as you stop taking tramadol and start drinking more liquids, constipation will gradually disappear.

Keep in mind that since you will be eating a lot less and doing less physical activity, especially during the first month, it can cause a smaller amount of stool formation. Drink lots of water, at least two liters a day (67 fl oz.) and increase your physical activity. If this doesn’t help, contact us and we will prescribe a soft laxative.

Smoking: It is very important you stop smoking, at least, during the first month after the surgery. Smoking inhibits adequate healing and increases thrombus formation, besides it is related to some lung problems. It also introduces gas into your new small stomach, which can cause severe pain (because of the distension), nausea and vomit.

If you are a smoker, you may use nicotine patches during this time, which might help to reduce anxiety once you stop smoking. Smoking the first month after surgery might cause important complications.

Physical activity: Physical limitations after a laparoscopic surgery are minimal. We insist that once you’re back to your room, after your surgery, you start walking. You may start by standing up and walking around your room and the hospital hallways. If you feel severe pain, you may rest for a while and try it again later.

Take care of your joints (knees and ankles) while you exercise. If you have any joint trouble or do not wish to put so much pressure on them, we recommend a stationary bicycle, water aerobics, or walking in water (keep in mind you should wait at least 15 days to submerge your wounds). At the beginning, you may feel weak because of your liquid diet but start slowly and try to increase gradually your activity.

When can I go back to work?

This is one of the most frequently asked questions because many of our patients need to go back to work. Since this is a laparoscopic procedure, limitations are minimal. If you have an office job, you will need 7 days before going back to work. If your job requires carrying or handling instruments that need more than 2kg (4.5lbs) of force, we recommend that you wait a month to get back, or talk to your boss, so you can have lighter assignments while your body recovers.

Walking: Once you recover from the anesthesia, it takes from 3-4 hours after the surgery for you to walk. It is crucial to do this in order to reduce a complication rate. Once you are discharged, you will be able to have 10-minute walks as long as they are light walks. One month after the surgery, you will be able to do all the walking you want. We suggest you wait at least two months to participate in walking or running competitions.

Driving: You can start driving as soon as you are discharged (usually two days after surgery). But if you are taking analgesics such as tramadol, your reflexes might be slower, and you might feel a little bit dizzy, we recommend not driving until you stop taking these medications.

Office Work: You can do your work from home or go to work as long as you remember to be careful with unintentional movements or bumping into people who do not know you just went under surgery.

Climbing Stairs: You will be able to climb stairs as soon as you are discharged. This is a laparoscopic procedure and climbing stairs represents a risk for hernias when there is an open surgery. However, we recommend not doing it so frequently, just when necessary. Try it by holding the handrail or someone else so the amount of force is on your hands. If discomfort or pain appears, wait a few days longer.

Work that requires moderate physical activity: Some people’s jobs are handling heavy tools, carrying boxed, or walking long hours from one place to another. These patients should wait two weeks to return to their duties. You may go back to work as long as you are instructed with less intense activities.

Exercise: You may walk right after surgery but you should wait at least one month to do it as exercise (fast pace and more than 20-30 minutes). Other activities such as gym, ball sports, swimming, etc., are required to wait at least two months. This is mostly because you will feel a little bit weak; now that you are getting used to eating less —intense exercise could also cause an umbilical hernia.

Sexual intercourse and sleeping on your stomach: You will be able to do these as soon as the pain lets you. This can be from 3 days to 2 weeks after the surgery.

In general, how will I feel after the surgery?

You will feel fine. You will be a little bit weak, pain will be bearable with limited activity and abdominal distension (this is from the gas and usually disappear in 2-3 days after the surgery but may last up to 10 days).You will too experience changes in bowl habits (less stool formation, changes consistency) and bruising near the incisions (they’ll disappear gradually). You will feel better each day.

Post-op Doctor’s appointment

Usually you will have 1 or 2 appointments after your surgery. During these visits, your surgeon will remove your drain (only in cases when a drain was placed) and will assess your post-op evolution.

If you’re a foreign patient, you will be able to return home 24 hours after discharge. Most of the time, your drain will be removed before you leave. If by any cause this could not be done, it should be removed by a doctor from your city (it doesn’t need to be a surgeon).

What is a drain?

A drain is a silicone tube connected to a reservoir. This tube is placed inside your abdominal cavity during surgery and we leave it there from 2 to 8 days after the surgery for prevention purposes. The possibility of a leakage is very low (less than 2%) after the procedure. In case it happens, the drain will help us to make an early diagnosis and thus treat it. Some bariatric centers do not leave drains after surgery, but truth is that leaving it or not is still a controversial matter among bariatric surgeons.

Most patients refer bearable discomfort with the part of the drain (silicon tube) that comes out of the abdomen, but usually patients tolerate it very well. Removing the drain is a pain-free, fast and easy procedure. You might feel a weird sensation when it is coming out.

*Surgical drain is generally used with gastric bypass, sleeve gastrectomy, or mini gastric bypass. However, gastric plication rarely needs surgical drain.

Nutrition

This is probably the most important part of the process. You will have to keep in touch (by phone, on-line, etc.) with your dietician at least for the first month. During the first month, you will meet him/her once a week. During the second and third month you will meet him/her every 2 weeks and for the next 9 months, once a month.

Remember that these appointments are considered in your surgery’s cost, so there is no excuse to stop communicating and although our dieticians are always ready to help, you may contact a dietician back home. The more specialists to help you, the better results you get.

Most patients reach their goal after a year from surgery or can also be far away from it. But still you should continue visiting your doctor or dietician at least once every 3 months during the second and third year and, afterwards, once every 6 months.

Here are the advantages of these visits:

  • You will be weighed on the same scale. Do not weigh yourself anywhere else, since normal variations between scales can make you feel anxious.
  • You will be asked questions regarding nutritional deficiencies in order to assess your vitamin and mineral status and, if needed, start supplementation.
  • Your hydration level will be assessed.
  • We will ask you to fill out some questionnaires to assess your sense of satisfaction level.
  • You will be asked for lab tests every 3 months to assess glucose, lipids, thyroid hormone, and creatinine levels. These studies may vary according to the patient.
  • Your health condition will be assessed. We would focus on sleep apnea, knee pain, gastric refluc, blood presure, among others.
  • You will be given advice on what exercise you should do. You will be given dietary plans evaluated for you body type, fat mass, weight, height, age, gender and expectations. The physician or dietician who will treat you will assess the best dietary plan for you, which you must strictly follow.
  • To a large extent, the short and long-term success will depend on it.

 

Bariatric Psychology

Experience has shown us that every bariatric patient requires a psychological approach before and after surgery. It is important to understand that this doesn’t mean that you are crazy. This therapies help to control anxiety, how to cope with social meetings without eating, how to socialize with your friends without having to eat as you used to, how to let everyone know you have had the surgery and to measure your sense of satisfaction level and quality of life, among many other aspects.

 

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