Post operative photograph of patient abdomen following laparoscopic (keyhole) right hemicolectomy, this small incision combined with fast track recovery allows the patient to go home only 48 hours after surgery.
Here are the main points of the Enhanced Recovery Programme:
- Planning your operation and discharge before you come into hospital
- Receiving optimum pain relief
- Getting out of bed as soon as possible after surgery
- Optimising nutrition; eating and drinking soon after surgery
- Giving early stoma care education (if necessary) Â
It is important to mentally prepare for the operation which may allow you home after only a few days.Â As soon as you are mobile enough to cope at home, eating with bowels starting to move and with pain control acceptable then you will be allowed home.
Stopping smoking will reduce the chance of getting a chest infection after the operation.Â At pre-admission you may want more information or see your Practice Nurse / GP for help and advice.
For discharge, if you live alone, you may wish a family member or friend to stay with you for at least a week once you are discharged from hospital.Â We recommend you make these arrangements before you come into hospital to not delay discharge.
High energy drinks may be offered before and after the operation to improve recovery; these may not be to every patients taste, however they provide essential nutrition to allow healing.
Thromboses (clots) in the legs are reduced by heparin injections and elastic (TED) stockings, which you will need to put on the morning of your surgery.Â You will need to wear these stockings at least until you are discharged home.
Before the operation your bowels are often cleared out by giving an enema or occasionally full bowel preparation if the whole colon needs to be emptied.
Why use a Laparoscopic (keyhole) approach rather than open (traditional) surgery?
This is a less invasive way than the traditional â€˜openâ€™ surgery with smaller scars and thus less wound problems.Â Three to four small holes are made in your tummy so that a camera and operating instruments can be passed into your abdomen.Â You may have another small wound used to take out part of the bowel which will usually be side to side (rather than head to toe direction) which causes less pain.
Fast track recovery helps both laparoscopic and open surgery types so can be offered to most patients undergoing gut surgery.
Some discomfort after surgery is normal but we aim to prevent pain especially if it restricts moving or deep breathing which are important to quick recovery.Â Oral (by mouth) tablets may be enough for some operations but the following summarises other forms of pain relief.
Because of the side effects we try to avoid opioids (like morphine) but use potent paracetamol via a vein in addition to using nerve blocks as well as epidurals are helpful to allow an enhanced recovery.
What is an epidural?
An anaesthetist places a very fine epidural tube into your back so that small quantities of pain relieving drugs can be administered close to the spinal pain nerves.Â This can block the pain messages in the nerves and reduce the pain you feel after the operation.
The epidural tube can be put in while you are awake (with local anaesthetic to numb the skin) or after you have been placed under general anaesthetic.Â A medical pump is attached to the epidural tube, which allows the pain relieving drugs to be given continuously.Â In this way the amounts of drugs given are carefully controlled by your nurse.Â After a couple of days the epidural tube is painlessly removed.
Why have an epidural?
An epidural makes the cut of the operation numb when the patient wakes aiming to reduce the need for other pain killers.Â The other benefits are to allow deep breaths and reduce the chance of clots in the legs (DVTs).Â If the epidural does not have the desired effect you may be offered Patient Controlled Analgesia (PCA) which involves the patient pressing a button when needed a machine gives a dose of painkiller.
Is there an alternative to epidural?
Yes.Â For some incisions a Painbuster is appropriate.Â This numbs the nerves at skin level, similarly to an epidural pump by pain relieving drugs to be given continuously.Â This, like an epidural, lasts for a couple of days providing prolonged pain relief.Â Unlike an epidural the Painbuster avoids the small risk of bleeding near the nerves of the spine and also allows the patient to be fully mobile as the device can be carried around the ward by the patient.
You will wake up after your operation in the Recovery Room within the operating theatre suite.Â Upon waking you may experience some discomfort in places other than the operation site.Â This is quite normal and you must not be worried or concerned.Â Sitting out of bed, moving legs and deep breathing and coughing are all encouraged in the days after surgery.
Your bowels may be erratic for a period of time after surgery.Â You may have a loose motions and a small discharge of blood on opening your bowels and it may take some weeks to regain a more predictable bowel habit.
Early nutrition has been shown to aid recovery and either milk or juice based drinks will be offered regularly which should be sipped over a few hours rather than drunk in one go.Â Chewing gum has been shown to encourage the bowels returning function earlier so you may want to bring some with you in addition to non-gassy drinks of your choice.Â When you are hungry this is a good sign that the surgery has gone well and the bowels are recovering well.
If it is likely you require a stoma you will ideally have been seen by a Stoma Nurse Specialist before the operation.Â It should be made clear whether this stoma (bag) is planned as temporary or permanent.Â Following your operation, the Stoma Nurse Specialist, or a ward nurse, will demonstrate how to clean your stoma, empty, and change your bag.Â You will then take an active part in your stoma care on a daily basis but help from close family members or next of kin is encouraged.
After you leave hospital, you will be seen by the stoma team at home (where possible) and will attend follow up appointments with them at their clinic.Â Their support is ongoing and they will provide you with contact numbers.Â You will be given an idea when a temporary stoma will be reversed, but this sometimes depends on your recovery and whether any other treatment is necessary.