Enhanced recovery after bowel surgery

How will my operation be done?

Your operation will be done in one of two ways; this will be either by laparoscopic surgery (keyhole) or open surgery.

What is laparoscopic surgery?

Laparoscopic surgery is known as ‘minimally invasive’ or ‘keyhole’ surgery. Not every patient can have keyhole surgery. Your consultant surgeon will discuss with you whether the keyhole approach is possible.

What does keyhole surgery involve?

In order to remove part of your bowel, 4 or 5 small cuts (5-10mm in length) are made in your abdomen into which small plastic tubes (ports) are inserted. Surgical instruments are passed through these ports to the inside of your abdomen. These instruments include a telescope and camera, which allows the surgeon to see inside. A harmless gas is pumped in to the abdomen to make this process easier. The diseased part of the bowel is then removed through a separate cut, which is approximately 6cm in length.

What are the advantages of keyhole surgery?

There is strong evidence that laparoscopic surgery results in:

• Less pain as the cuts are smaller
• Less need for pain killers afterwards
• Less blood loss at the time of operation
• Reduced hospital stay
• Quicker recovery plus return to normal daily activities
• You are able to start eating and drinking sooner
• Your bowels start to work again sooner
• A better result cosmetically as the scars are much smaller

Are there any risks?

The risks of this type of surgery are the same as for any type of bowel surgery:

• Bleeding
• Blood clots (deep vein thrombosis)
• Infection (usually in the chest, water works or wounds)
• The join (anastomosis) in the bowel may not heal and you will need another operation to fix this
• Injury to other internal organs (such as small bowel, bladder)

Are there any alternatives to keyhole surgery?

Yes. In some cases, the operation cannot be performed or completed through the keyhole method and a decision will be made to perform the operation in the traditional way. Factors that may increase the possibility of choosing or converting to the ‘open’ procedure may include:

• Complications at the time of surgery, e.g. bleeding
• Realising the bowel is more diseased than was previously thought
• The presence of scar tissue (adhesions) making the surgery difficult
• Inability to identify internal organs
• Obesity

The decision to perform the open procedure is a judgment made by your surgeon either before of during the actual operation. When the surgeon feels that it is safest to convert the keyhole procedure to an open one; this is not a complication, but rather sound surgical judgement. The decision to convert to an open procedure is based strictly on patient safety. This is to ensure the safe removal of the bowel and that an adequate join of the remaining bowel can be made. If this does happen it may mean a slightly longer recovery and hospital stay.

What do I need to prepare at home before I leave for the hospital?

Please tell your family and friends that you will be going into hospital. It is a good idea to make a list of their telephone numbers to bring to the hospital with you.

What do I need to bring with me into hospital?

Please bring with you all of your usual medication in its original packaging. Please bring a nightgown or pyjamas, slippers and a dressing gown. You will need some toiletries, as well as a box of tissues or hand wipes. You may prefer some light day clothes to wear whilst in hospital.

We strongly advise you not to bring in any valuables. Please ask a friend or relative to take them home. If this can’t be helped, please hand in such items to the ward staff. Your valuables will be locked in a safe and you will be given a receipt for them.

What will happen before the operation?

After you have been seen by a doctor in the outpatient clinic, you will need to attend the “Pre-Assessment Clinic”. An assessment will take place to make sure that you are fit to have an anaesthetic. At this assessment you will be asked to answer some general health questions. A nurse will record your blood pressure, pulse, weight, height and lung function (peak flow). A urine and a blood sample will also be taken. You may require an EGC (heart tracing) or X-ray.

When do I come into hospital?

You will be admitted to the ward either the evening before your surgery or the morning of the operation itself. This will be confirmed in a letter from the waiting list office, even if you have already been given a date by the surgeon.

What happens when I am admitted?

A nurse will check all your information with you, including contact details for next of kin. You will be requested to wear an identity bracelet at all times whilst you are an inpatient. The anaesthetist, physiotherapist and colorectal nurse specialist may also see you.

What can I eat and drink before the operation?

You may eat a normal evening meal the night before your operation. As well as this evening meal you will be asked to take a flavourless drink called Pre-Load. This drink is specially designed to give your body energy to help you recover. After this, you should not have anything more to eat.

On the morning of your surgery you will be given a further drink of Pre-Load. You will be encouraged to drink clear fluids up until two hours before your surgery.

Will I need to have any bowel preparation, laxatives or enemas?

This will depend on the section of the bowel to be removed. Some patients will not need bowel preparation, some will need an enema, and some will have full bowel preparation. Your surgeon will decide this.

Will I need a stoma? (sometimes called an ileostomy or a colostomy)

A stoma is a part of your bowel that is brought through to the surface of your stomach and a bag is worn over this to collect the faeces, rather than opening your bowels in the usual way. The bag is attached to the skin on the abdomen.

If it is likely that you will need a stoma bag, this will be fully discussed with you before the operation including what a stoma is and instructions on how to look after a stoma. The stoma nurse specialist will see you beforehand and mark the most appropriate place on the abdomen for the stoma to be placed.

The stoma nurse specialist will also be able to show you how to look after the bag and will check that you fully understand how to do this before you go home from hospital.

What will happen on the morning of the operation?

You will be seen by the anaesthetist who will explain to you the method of pain relief that will be used. You will be seen by the surgeon who will be able to answer any questions that you may have about the operation.

The surgeon may ask you to sign a consent form if you have not done so already in the outpatients department.

The nurse will give you a hospital gown and anti-thrombosis stockings (to help your circulation) and will ask you to remove any make-up, dentures, contact lenses, jewellery (except wedding rings).

What happens in the anaesthetic room?

Drip lines will be inserted into the veins in your arm. Fluid drips are left in place for the first day after your operation. Many of our patients will have an injection into the back to provide pain relief. For some this will be one injection (spinal analgesia).

For others a tube will be inserted into the back that connects to a pump which provides a continuous flow of pain killer (epidural analgesia). Both are excellent ways to keep you comfortable after the operation, and will be discussed with you beforehand by the anaesthetist. The epidural, if present, will remain in place for the first day or two after your operation. Following this you will be sent off to sleep (general anaesthesia).

What happens in theatre?

Before your operation, a small tube will be placed in your bladder to collect urine. This will remain in place for a short period after the operation. You will be given a dose of antibiotic to prevent infection, and injections to try and prevent you from getting blood clots. You will have your operation performed.

What will I feel like when I wake up?

You will wake up quickly in the operating theatre or the recovery room. You will usually be given extra oxygen to aid recovery. The nursing staff will closely monitor you as you wake up. This is routine after a general anaesthetic. When you are fully awake the nursing staff will accompany you back to the ward.

How long will it all take?

The day of your operation you will be off the ward for most of the day. There will be time in the anaesthetic room when you will be connected up to the monitoring equipment, the operation itself, and there will be time in the recovery room afterwards when you are waking up after your operation.

What will happen the night of my operation?

You will be encouraged to practice deep breathing and to move your legs around. You will be assisted by the staff to get out of bed for two hours. You may drink whatever you like after your surgery. It is important to eat and drink early after your operation and you will be encouraged to do so. You will be monitored quite closely during this time.

What can I eat after my operation?

You will be able to eat whatever you like straight away after your operation. The fluid drip will be removed from your arm the day after your operation. It is important to drink plenty of fluid and to start eating straight after your operation, as your body will need the nutrition to help with the repair process.

If you do not feel like eating solid food, then liquid Nutrient drinks are available however eating little and often for a few days can be beneficial towards recovery.

How quickly will I be up and about?

The day after your operation you will aim to remain out of bed for eight hours. You will be assisted by the physiotherapists and nurses to walk up and down the ward. We aim for 4 walks of the length of the ward.

It is important to get moving very soon after surgery as this reduces the risk of clots in the legs and chest infections. For those with epidurals, this will usually be removed after 36 to 72 hours. You will be given pain-killing tablets to take.

When will I be discharged?

We expect you to be in hospital between three and five days. Before you go home, your pain will be well controlled on tablets. You must be eating and drinking and you need to be able to walk about safely.

It is not essential to have someone with you at home, but you may feel more comfortable if family and friends are available to help. We will make sure that you are able to manage when planning to discharge you from hospital. You will be given a supply of any tablets that you need before you leave.

What will happen after I am discharged?

In the first few days after discharge you will receive a telephone call from your key worker or ward to check that you are alright. If you have a stoma, the specialist stoma care nurse will contact you within the first few days to check that you are managing with it.

You will be given an appointment to be seen in the outpatients department to check that you are recovering well, and to discuss the results of any tests done on the piece of bowel that has been removed.

How will I feel when I get home?

You are likely to get tired easily and need to rest during part of the day. This improves with time. When you return home you should take things easy for two weeks. Tiredness is very common and will last longer than you think, up to 4-6 weeks after the operation. Do notworry, this is normal and will pass in time. Instead, make a plan for yourself of gradually increasing your activity and the things you do for yourself in the following weeks. It is important to mobilise everyday to aid your recovery. It is also helpful to plan a ‘rest time’ during the day when you can be undisturbed. On the whole, resting on your bed rather than in a chair at this time is more relaxing.

Eating and drinking

Some people find that their appetite is small and they get a bloating feeling or indigestion after meals. You are advised initially to try eating small meals at regular intervals to reduce the likelihood of digestive problems occurring. It make take several weeks before your appetite returns and you might find you have no taste for food and drinks that you previously enjoyed. These symptoms usually resolve themselves as you become more active. Drinking plenty of fluids is important and can help your recovery. Aim to drink at least 8-10 large mugs of fluid per day, if you want to avoid getting up in the night, avoid drinking too much after 6.00pm to 8.00pm. Soups and milky drinks are nourishing if you can’t face a meal. A small amount of alcohol can improve your appetite and is normally not harmful. As everyone knows some foods can cause more wind, so try introducing new foods gradually into your diet. If you think an item upset you, try it again after a few weeks. In time you will be able to enjoy your food as before. If you are in any doubt about the right sort of food to eat ask for advice.

How will my bowels work?

You may be discharged before you have had a bowel action. You may get occasional griping pains, which lasts a few minutes before wearing off. This is quite normal, and is a sign that your bowel is beginning to work normally. Peppermint cordial diluted in warm water can help to relieve some of this discomfort. You may have an erratic bowel function for a short period after surgery, it can be normal for you to have diarrhoea and go to the toilet several times a day. This should become manageable with time although the way in which your bowel works may never return to how it was prior to your operation. If you have persistence or long term problems with your bowel you should contact the Colorectal Nurses Specialists for further advice and support.

The operation, changes in diet, reduced activity and the use of some drugs can lead to irregular bowel habits but this usually settles with time. If you have diarrhoea, drink plenty of fluid and have extra salt in you diet e.g. Bovril drinks, crisps, add salt to meals to replace that which is lost. If it persists and you are concerned ask for advice. Sometimes you can become constipated, this might be a side effect of the painkillers you have been prescribed. Straining can be uncomfortable particularly after abdominal surgery so it might be helpful to take a mild laxative. If you are in any doubt ask for advice.

Rectal discharge

If your back passage has not been removed but you have a stoma you may still have the urge to open your bowels. This is common and quite normal. If the sensation is particularly strong, sit on the toilet but don’t strain. You may pass mucus (jelly/slime) or stool, this is quite normal. Try to keep the skin around your back passage clean and dry to prevent soreness.

Rectal discomfort or pain

This can occur in some patients when their back passage has been removed. You may experience a discharge from the wound as it heals. If concerned ask your community nurse or stoma nurse to check this. Whilst pain or discomfort usually resolves spontaneously when the wound has healed this may take as long as 6 months. If it continues you should mention it at your hospital clinic visit.

Will my stoma be checked?

The Stoma Care Nurse will arrange to visit you within one week of discharge, a second visit will be planned as appropriate. During the visit the nurse will check the stoma and assess the way in which you are caring for it. How to obtain your supplies and disposal of your bags will be discussed. Remember to write down any questions you may have regarding your stoma, operation or recovery, the nurse will be more than happy to answer these.

Wound healing

All wounds progress through several stages of healing and you will notice these changes over the coming weeks. The following are frequently experienced:

• Unusual sensations, such as tingling, numbness (which could be permanent) or itching.
• A slight hard lumpy feeling as the new tissue forms.
• Slight pulling around the stitches as the wound heals.

Don’t pull off any scabs, these are the body’s ‘natural dressing’ to protect the new tissue underneath, they will fall off when ready without help. Do seek advice if the amount of pain in your wound increases, if the amount of redness and/or swelling increases and if there is any discharge from your wound. These symptoms might suggest a wound infection

Sleeping

Changes in routine and restricted movement can cause difficulty in sleeping. Some people are woken by discomfort caused by sudden movement. Taking a painkiller at bedtime may help you relax and get a better nights sleep.

Bathing and showering

It is quite safe to get your wound wet 2-3 days after your operation, unless advised otherwise. There is no evidence to suggest that adding salt to the bath aids healing, it is more likely to make your skin dry and uncomfortable.

A nonslip mat will reduce the risk of slipping. It is reassuring to have someone else in the house when you first take a bath, even if actual help is not needed. You can use soaps and take a bath or shower as often as you want. If you have a stoma bath or shower with the bag on until your wounds have healed.

Clothing

Wear what you are comfortable in. At first your tummy may feel swollen and tight clothing might be uncomfortable. To begin with loose fitting clothing and tracksuits may be more comfortable.

Driving

The time at which you can safely start driving varies with what type of operation you have had but is usually 6-8 weeks post-operatively. Ask for specific advice but do remember that your movement and strength must be up to coping with an emergency stop as well as normal driving. You are advised to check with your insurance company.

Sexual relations

There is no rule about the time at which you can resume your usual sexual relationships. You can start as soon as you are ready, but erections may be incomplete for some. Be patient. Ask for advice if you are worried, experience problems or are concerned about your usual contraceptive methods (especially the pill).

Returning to activities

At first, discomfort in the wound will prevent you from attempting too much and act as a warning, particularly movements that involve bending and stretching (e.g. reaching high and low shelves), lifting heavy weights (including small children) and pushing or pulling (e.g. vacuum cleaning or mowing the lawn). Similarly standing for long periods can be tiring. If help is available for the first two weeks after discharge it is very useful. After 4-6 weeks you should be beginning to feel fit enough to resume such activities. More strenuous sports and activities should be resumed gradually after this time. It normally takes about three months for complete healing of the abdominal muscles to occur. If unsure, ask when you can resume sports and exercises

Mobility

A gradual increase in the amount of exercise you take is helpful, starting with a short walk two or three times a day and increase the distance over the next few weeks. If specific exercises are needed, ask before leaving hospital. Climbing stairs can be surprisingly tiring but a useful way of getting exercise and judging your progress.

Work

The time at which you can return to work depends on both the type of surgery you have had and type of work you do. It is better to feel completely well before you return as many people feel tired and find concentration difficult to start with. Hospital staff or your GP can give more specific advice.

In summary

Remember, you have had a major operation. Listen to your body, rest in bed when you feel tired. Try to do gentle exercise when you are feeling restless. Eat when you feel hungry, little and often if needed. Remember it is important to drink plenty of fluids. Give your bowels time to settle. Do not worry unnecessarily; we are only a phone call away.

If you have any of the following symptoms

• Severe pain
• Pain lasting more than 2 hours
• High fever
• Feel generally unwell
• Not managing to eat or drink
• Bowels working very erratically or not at all
• Nausea or vomiting

You should contact:

• Monday to Friday, 8am to 4pm - Your Key worker on 01709 427154

Remember to take things easy at first. Get plenty of rest, but gradually increase the amount of activity you do - it’s a balance: plenty of rest, gentle exercise and good food.

Rotherham Cancer Care Centre
93 Badsley Moor Lane, Clifton, Rotherham

Beating Bowel Cancer
020 8892 5256
www.bowelcancer.org

CancerBACUP
0808 800 1234
www.cancerbacup.org.uk

Bowel Cancer UK
08708 50 60 50

Bowel Cancer Advisory Service
020 7381 9711
www.bowelcanceruk.org.uk

National Association for Colitis and Crohn’s Disease
0845 130 2233
www.nacc.org.uk

Colostomy Association
0800 587 6744

Sitwell Ward

01709 424462

Ward B5

01709 426960

Your Key Worker

01709 427154