Preparing for Surgery

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More than 25 million Americans undergo surgery every year, most of them women. Many women will face a recommendation for surgery that involves their reproductive system, typically called gynecologic surgery. For example, hysterectomy—surgery that removes the uterus and sometimes other parts of the reproductive tract—is the second most common gynecologic surgery after Cesarean section.

Facing surgery can be a frightening experience fraught with questions, doubts and uncertainties. However, most surgeries are elective, meaning that you decide if surgery is the best option for you and elect to have the procedure. This decision process often gives you needed time to prepare, which is an important step. Research suggests that women who prepare mentally and physically for surgery have fewer complications, less pain and recover more quickly than those who don't prepare.

Within 20 years of the invention of anesthesia in the mid-19th century, operations were developed for conditions ranging from appendicitis to uterine fibroids. Enthusiasm for gynecologic surgery was especially intense, and the first hysterectomy was performed in 1843 in Manchester, England.

Today, the trend in gynecologic surgery is toward less invasive techniques that don't require surgeons to cut into the abdomen with large incisions. Doctors are even trying incisionless surgery—a new technique where internal organs are removed through body orifices such as the mouth or the vagina. Also, new, faster-acting anesthetics have been developed that have fewer side effects than traditional anesthetic agents.

Settings for surgery have changed, too. Not long ago, having surgery meant being admitted to the hospital a day ahead and discharged a week later. Today, more than half of all surgeries, including many gynecological procedures, are done on an outpatient basis. Outpatient surgery refers to operations that do not require an overnight hospital stay. Instead, the surgery is performed at an ambulatory surgery center or a health care professional's office, and you return home in less than 24 hours. Now there is also a choice between hospitals' ambulatory surgery centers and free-standing ambulatory surgery centers, which are becoming more popular and can often be found in the suburbs, even in shopping malls. They are physically separate from—and sometimes even distant from—a hospital.

Generally, outpatient, or ambulatory, surgery is appropriate for simple procedures that can be done in 60 to 90 minutes and don't require a person to be closely monitored afterward. Outpatient surgery offers several advantages over surgery that requires hospitalization, such as:

• a lower risk of infection after surgery

• recovery at home

• fewer delays and shorter waiting times

• lower cost

• less disruption of your schedule

However, if a large incision has to be made or if the risk of complication is high, same-day surgery may not be an option. Outpatient surgery is not for everyone. Women with chronic conditions such as diabetes, heart disease, or high blood pressure (hypertension), or who are otherwise at risk for complications that could require hospitalization, might not be eligible.

Same-day surgery also puts more responsibility on the patient to complete the necessary preoperative tests, manage pain medications, keep incisions clean and follow through with postoperative care on their own. A woman who has small children to care for at home may be unwilling or unable to take on the added responsibility and may not be a good candidate for same-day surgery. If you face a recommendation for surgery, be sure to consider which type of setting will work best for you.

Such advances in surgery may make it more convenient, but they haven't necessarily made it less stressful. Hormones released in response to stress can cause symptoms ranging from headaches to high blood pressure. Stress hormones can also weaken the immune system and disrupt the body's ability to manage pain and infection.

Preparing Emotionally

Surgery also has an emotional impact. A woman who has heard that a hysterectomy will ruin her sex life or leave her tired for months, for example, may become depressed, fearful or angry with her body. For some women, the anticipation of being hospitalized and separated from family members makes coping difficult. Even simple procedures done in a doctor's office can provoke a strong reaction.

Some experts advocate preparing for surgery through a series of relaxation therapies: deep breathing, positive thinking and visualization—imagining or mentally seeing—a positive outcome from surgery and a quick recovery period, for example.

Preparing Physically

While emotional preparation is a necessary, often-overlooked step, preparing physically, is also important for a successful surgical outcome. In the weeks before your surgery, you should:

• Stop smoking and avoid excessive alcohol

• Eat a well-balanced diet including plenty of foods rich in vitamin C, which may help promote tissue healing.

• Avoid aspirin or other aspirin-like medications that interfere with blood clotting for five to seven days before your surgery.

• Exercise regularly to build energy and maintain strength.

• Ready your home, including preparing food and rearranging furniture if necessary.

• If necessary, arrange for someone to take care of your children while you are in the hospital.

If you decide to have surgery, discuss the following with your health care professional:

• Determine when elective surgery can be scheduled, taking into consideration your job and family commitments. Sometimes it is not possible to know the exact time of the surgery until the business day before the actual date.

• Learn which routine laboratory tests may be needed, which may include x-rays, blood tests, urine tests and an electrocardiogram

• Ask if you need to change the schedule and dosage of any medications you are taking.

• If you are diabetic, discuss how to manage or modify your insulin intake during the immediate preoperative period when you are not eating.

• Since there are often several ways to perform a specific procedure, ask your doctor to explain the surgery and how it is done and to explain if there is more than one way to do it. For example, if you have fibroids, you have an option to choose between a hysterectomy (removal of the entire uterus, which can be done in several ways), a myomectomy (removal of the fibroid tumor alone), a uterine artery embolization (cutting off blood supply to the uterus), plus a couple of other noninvasive ways to remove fibroids.

• If you are preparing for elective surgery, you get to choose your surgeon and may want to do some homework about the surgeon: What are his/her qualifications? Board certifications? Sub-specialities? How many similar procedures has the surgeon performed? What is the success rate? Remember, however, that the most important reason to choose a surgeon is that you feel respected and listened to; you communicate well with the surgeon; and you are not intimidated by him or her. Discuss the risks and benefits of each alternative.

Legal Considerations

Once you've decided on surgery, had the necessary tests done and prepared mentally and physically, you'll be asked to sign a consent form. Now may also be a good time to consider donating blood for your surgery, if you wish to, and drawing up advance directives. These instructions communicate your health care plans if you cannot speak for yourself in the future.

There are two kinds of advance directives: a living will and a health care proxy. States differ in the directives they recognize. Discuss your wishes with your health care professional and your lawyer. State-specific directives are available from the National Hospice and Palliative Care Organization Web site at http://www.caringinfo.org/, or you can obtain one from your local health department, state medical associations or a hospital admissions office.

A health care professional is required to have a detailed discussion with you before your surgery so that you are fully informed when making the decision whether to have it. This is called obtaining your "informed consent" to have the procedure. The informed consent process should include discussion of the risks and benefits of the proposed surgery.

Consent forms differ from one health care professional to another and may include permission for additional procedures to be performed if needed. Ask to sign the consent form several days in advance to avoid being confronted with a list of risks immediately before surgery, which can create anxiety. Do not sign the consent form until you understand and feel comfortable about what is being done. Don't let this part of the process feel rushed. Ask questions if you need to.

Before surgery you may also be asked to sign a form allowing a blood transfusion to be performed, if necessary. Normally, blood donated to the Red Cross four to six weeks in advance of your surgery is shipped to the hospital a few days before your surgery. However, you can also donate your own, called an autologous blood donation. Or you can ask family members or friends with the same blood type to donate units of blood for you. You'll need to inform your surgeon whom you have chosen to donate blood for your use.

If you're considering autologous blood donation:

• Ask your surgeon if you are likely to need blood and if so, how much.

• Consider taking iron supplements to rebuild your blood supply before surgery.

Call the Red Cross and ask about fees and insurance coverage and about freezing your blood if your surgery is delayed.

Financial Considerations

Familiarize yourself with the extent of your medical benefit plan before your operation so you will know what portion of the costs will be your responsibility. Your physician's office staff may be able to help you find out how much your medical benefit plan will cover. If your medical benefit plan will not pay all of the anticipated costs and you cannot afford the difference, then discuss this situation with your surgeon to see if you can work out an acceptable solution.

Some procedures and some health plans require "pre-authorization" before your operation. Become familiar with your insurance plan requirements to avoid unpleasant surprises after your surgery.

Understanding Pain

Knowing what to expect after surgery is as important as knowing what to expect beforehand. Pain is an inevitable part of surgery. Pain is the body's way of sending a warning to the brain that it has been damaged and needs attention. Although a normal reaction to surgery, pain can interfere with recovery by:

• causing you to suppress coughs, which can lead to a build-up of fluid in the lungs and pneumonia

• slowing the return to normal digestion

• preventing you from getting out of bed, raising the risk of blood clots

• increasing stress, depression, and anxiety

There are several ways to relieve pain after surgery. Narcotics, such as morphine and codeine may be prescribed for severe pain following surgery via IV, pills or patches. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or other non-narcotic pain relievers may also be used, either as liquids or in pill form. Local anesthetic injections or anesthetic creams and patches may help prepare your body for a procedure or relieve pain afterward.

Depending on the type of surgery you are having, you may also be given pain relievers through patient-controlled intravenous analgesia (PCA), which is usually used in hospitals for acute pain following surgery. In PCA, the patient is connected to a machine called a PCA pump. When the patient pushes a control button, the machine delivers a dose of narcotic or other pain reliever intravenously. The doses are smaller than what would be given by injection, but because the drug goes directly into the bloodstream, relief can occur within seconds.

Ask the surgeon or anesthesiologist to discuss these options with you beforehand. Other nonmedical approaches to pain management can be very successful. These may include:

• relaxation techniques

• applying heat or ice to the surgical site

• massage and stretching exercises

When preparing for surgery, discuss with your health care professional what possible pains to expect after your procedure and how to best manage any possible symptoms.