Chapter 15
Postoperative Care: Immediate and Follow-up Instructions
Postoperative care is very important for the successful outcome of the surgical procedure.
Postoperative care begins immediately after the reversal of the patient from the anesthesia. At this stage although the patient has regained her consciousness, she is still drowsy owing to the effect of the drugs. Also, in the immediate postoperative period the patient is unable to take care of herself and requires assistance. The patient should not be left unattended immediately after the surgery in her drowsy state until she is moved to the recovery room. If unattended, she could fall from the operation table which would be a serious issue medically as well as legally.
The scrub nurse should clean the patient’s operative area with the antiseptic solution and dressing of the incisions should be performed preferably with wash proof dressing. In this way the patient can take a bath without soaking the wound. The abdominal wall and the perineal area are cleaned with the sterile warm water and dried with the sponge. The vaginal area should be inspected for bleeding. A sterile perineal pad is then applied. Oro-pharyngeal cleaning or suction is performed to clear out any mucus. The patient plate of electrosurgical generator is removed and the skin should be inspected for any accidental burns possibly owing to a faulty patient plate.
The patient is moved carefully off the operation table using a roller plate. A minimum of two persons are required to support the patient’s head and feet, while moving on the shifting trolley or the recovery bed. The wheels of the recovery bed or trolley should be locked while moving the patient. The attending nurse should give careful attention to the patient’s indwelling bladder catheter and IV line.
The patient is then wheeled out of the theater and moved to recovery room for observation. The circulating nurse should accompany the patient at the time transfer to the recovery room. The patient should remain in the recovery room for 45–60 minutes for immediate postoperative care. A dedicated nurse should be present in the recovery room to receive the patient. The circulating nurse should inform the recovery room nurse about the nature of the surgery performed, specific intraoperative events, names of the parenteral drugs infused such as antibiotics, etc.
The recovery room nurse should note the vital parameters of the patient, the quantity of the urine and its color. The basic parameters such as pulse, non-invasive blood pressure and SpO2 are monitored in the recovery room with the help of dedicated multiparty monitor. Particular attention should be given to the blood pressure as the patient could have hypotension immediately postoperative owing to the continuation of the effect of the anesthesia drugs used for the reversal of the patient.
Once the patient is stabilized in the recovery room, the patient’s relatives are informed regarding the status of the patient. Relatives can be allowed to meet the patient in the recovery room. The operating surgeon provides instruction regarding the postoperative orders. The surgical process is addressed in brief to the patient’s relatives during this time. The surgeon should mention any specific concern to the relatives. Once the patient is totally awake and hemodynamically stable, she is then transferred to the postoperative ward or the patient’s room. The recovery room nurse should record the patient’s vital parameters at this stage.
A receiving nurse should accompany the patient, while transferring to the patient’s room or the postoperative ward. Once again the vital parameters are noted.
The patient should have complete bed rest in supine position. DVT prevention sequential pressure cuff use is continued on the calf muscles until the patient is ambulatory. The patient is kept nil per oral for a minimum 6–8 hours following the surgery in an uncomplicated straight forward surgery. If the surgery involves more than 2 hours with more bleeding than expected or involves release of bowel adhesions, then the patient is kept nil per oral for 12 hours. This is usually the operating surgeon’s decision. After 6–8 hours the patient is provided with the clear liquid diet. The senior author prefers to provide a routine diet after 24 hours. The patient is instructed to avoid spicy food items to avoid additional gastric irritation.
The senior author prefers to keep the indwelling bladder catheter for a minimum of 6–8 hours following the surgery in an uncomplicated case or surgery which involves minimum bladder adhesiolysis. In case of traumatic bladder dissection the catheter should be kept for a longer duration. This decision should involve a consultation with a urologist.
The practice of administration of intravenous antibiotics depends upon the local practice. The author prefers to give a minimum of three doses of intravenous prophylactic antibiotics such as third generation cephalosporins. One dose is given at the time of induction of anesthesia for the surgery and two doses are given in the postoperative period 12 hours apart.
Postoperative pain is managed by intravenous administration of NSAID or paracetamol (IV) at 8 hourly duration.
Usually patients are ambulatory within 8–12 hours following the surgery. The DVT prevention stockings and the DVT prevention sequential pressure pump are discontinued once the patient is ambulatory.
The senior author prefers to discharge the patient 24–48 hours following the surgery. The practice of discharging the patient from the hospital is entirely individual and depends upon many factors such the hospital norms, type and duration of surgery, coexisting medical illness such as diabetes, expectation of the patient and postoperative care and facilities available at the patient’s home.
At the time of the discharge, patients are provided with the detail summery of the surgery. The photographs of the intraoperative anatomy and pathology of the pelvic organs can be provided in a print format. The patient is instructed to take bed rest at home and to minimize physical activity for minimum 6–7 days following the surgery. An oral antibiotic is prescribed for next 5 days. Pain medication is prescribed along with the oral antacids.
Patients are counseled about postoperative mild to moderate pelvic discomfort which may last at least for a week following the surgery. Patients should be counseled about postoperative vaginal bleeding 2–4 weeks following the surgery. In senior author’s experience nearly 4–5% of patients of the laparoscopic hysterectomy present with postoperative vaginal bleeding. This could be explained on the basis of possible disruption of the epithelization of the vaginal vault owing to increased abdominal pressure secondary to the strenuous activity.
The patient is advised to restrict the strenuous physical activities such as exercise, lifting of heavy weights, etc. for minimum period of 4–6 weeks following surgery. Coitus should be avoided for minimum 6 weeks following the surgery. The above activities can interfere with the healing of the vaginal vault and can cause bleeding per vaginum and dehiscence of the vault of the vagina.
The patient should have a follow-up check up after a week. She should also be provided with the telephone number of the emergency care in the hospital.