33. Postoperative Restrictions After Laparoscopic Operations
Robert N. Cacchione, M.D.
Gerald M. Larson, M.D.
The postoperative restrictions and limitations for seven frequently performed laparoscopic procedures are described in this chapter. For each operation, we give guidelines for six activities of daily living usually covered in the doctor’s discharge instructions. Although there are increasing amounts of data to guide the surgeon in managing patients before and during operative procedures, there are few published data to assist in managing patients postoperatively. The infor- mation we present here represents what we believe to be reasonable discharge guidelines based on our experience and judgment. We note instances where pub- lished data exist.
A. Laparoscopic Cholecystectomy
1. Diet: After leaving the recovery room, the patient can start on liquids and be advanced to a regular diet as tolerated. Most patients tend to stay on liquids or a light diet the first day. An occasional patient experiences nausea related to either anesthesia or the procedure and needs intravenous fluids and an antiemetic for a variable period of time. There is also a 3%–10% incidence of a postoper- ative ileus, which will postpone the onset of appetite and eating.
2. Bath/shower: Wait 24 hours for skin incisions to seal and then bathe as patient’s activity level allows.
3. Activity: There is no restriction to walking and stair climbing. The patient should use incisional pain as an endpoint to exertion. We instruct our patients that if a particular activity hurts, do not do it. Moderate lifting is not harm- ful and should be governed by incisional discomfort. Most patients can easily lift 25 pounds by the first week and resume preoperative activity by 2 weeks.
4. Exercise/sport: Walking is preferred to running for the first 10–14 days, but running would not interfere with patient healing if this activity is not painful. We usually advise patients against weight lifting and contact sports for 4 weeks in most instances; after 4 weeks, normal activity and exercise are encouraged.
5. Driving: Resumption of driving depends on mobility, reaction time, and the patient’s ability to respond to any road hazard. Before driving, the patient should sit in the car, behind the steering wheel, and go through the motions of
stepping on the gas and brake pedals and should also use the shift. Similarly, the patient should turn to the right and look out the rear window of the car. Driving can be resumed provided that these activities are not painful. For most patients who were driving before the operation, their reflexes and faculties will be back to baseline in 1–2 weeks.
6. Return to work: The decision to return to work is multifactorial and based on the physical demands of the job, the patient’s motivation, and the duration of sick time allowed by the employer or the insurer. If the patient follows an uncom- plicated course and has a sedentary or nonlifting job, there is no physiologic basis for not working during the first week postoperatively. Frequently fatigue is a factor and patients often choose to resume work on a half-time basis or on light duty. In a comparative study of American and French patterns of postop- erative care regarding this question, we found that after laparoscopic cholecys- tectomy 63% of the Americans and 25% of the French returned to work within 14 days of the operation.
B. Inguinal Hernia Repair
1. Diet: Laparoscopic inguinal hernia repair is performed on an outpatient basis at our institution, and as such, most patients are discharged within several hours following their procedure. These patients may begin a liquid diet imme- diately upon discharge from the recovery room. Their diet is advanced to regular food as tolerated. Nevertheless, most patients tend to have some degree of nausea related to the anesthesia, and for the first postoperative day tend to stay on a liquid or light diet after which they return to a regular diet. Unless pain/me- dication-related, it is unusual for hernia patients to develop an ileus or dietary issues.
2. Bath/shower: Nearly all patients are closed with subcuticular stitches.
They are instructed to wait 24 hours before removal of bandages and then are allowed to bathe or shower.
3. Activity: This is certainly the most controversial area following laparo- scopic inguinal hernia repair. Our practice is to not restrict walking or stair climbing. We instruct patients to use their incisional pain as an endpoint to exer- tion. Patients are instructed to slowly introduce physical activity into their daily routine over the first week. They are instructed not to engage in physical activity that causes an increase in incisional pain. Most patients are able to lift moderate amounts (i.e., 5–10 pounds) by the end of the first week. By the end of the second week, patients should have resumed nearly the full range of their daily activities.
A recent study compared laparoscopic to open repair of inguinal hernias in which patients completed a 6-minute treadmill test. The results suggest that it is reasonable to expect patients to return to usual daily activity in 1 week. This level of activity is separate from maximally strenuous physical activity.
4. Exercise/sport: For the first 2 weeks following laparoscopic inguinal hernia repair, we encourage the patients to engage in walking and stair climb- ing. Lifting during this period should be limited to 5–10 pounds. Patients may resume graded increases in activity as the incisional discomfort permits. After 2 weeks of a limited exercise regimen, patients may resume running, likewise
on a graded schedule of introduction. After 1 month, a gradual schedule of weight lifting and contact sports may be resumed. There are only occasional patients who, because of continued discomfort, are unable to resume full activ- ity at the end of 1 month following laparoscopic inguinal hernia repair.
5. Driving: Resumption of driving depends on mobility, reaction time, and the patient’s ability to respond to any road hazard. For most patients who were driving before the operation, their reflexes and faculties will be back to baseline by 1–2 weeks. As a general rule, patients who require narcotic analgesia should not be operating motor vehicles while under the influence of these prescription medications. As mentioned in the previous section, the patient should not begin driving if the physical activities required (movements of feet, arms, and upper torso) are painful.
6. Return to work: As with laparoscopic cholecystectomy, the decision to return to work is multifactorial and based on not only the operation performed but also the patient’s desire to return to work as well as the nature of the patient’s job. Those patients who work at sedentary or nonlifting jobs are often able to return to work during the first week postoperatively. Those patients who have occupations that require more vigorous activities, such as restaurant waiters/wait- resses or store clerks, may be comfortable enough to return to work at the end of 2 weeks. For those patients who have highly physically demanding jobs, such as construction workers, police officers, and fire-fighters in whom good physical conditioning is necessary for the safe execution of their job, we sometimes recommend longer periods of abstinence from work, ranging up to 4 weeks.
As a general rule, however, most patients are able to return to work when they are largely painfree. Frequently this occurs at approximately 2 weeks post- operatively. This notion is supported by many of the studies comparing laparo- scopic and open inguinal hernia repairs in which return to work is studied as a parameter.
C. Ventral Hernia Repair
1. Diet: At what point the patient is ready for liquids and solid food after ventral hernia repair depends on the function of the gastrointestinal tract and whether an ileus is present. In our experience, this time interval is quite variable because it is related to the size of the hernia(s), the difficulty of the dissection, the extent of adhesions, and the duration of the operation. Most of these patients will be admitted to the hospital for 1 day or more, except those with small (3–
5 cm) hernias that are readily repaired on an outpatient basis. If ileus and nausea are not present, these patients can be started on liquids the night of surgery and rapidly advanced to a regular diet.
2. Bath/shower: Size of the hernia and the extent of the repair usually cor- relate with incisional pain and patient discomfort postoperatively; therefore, although in theory a patient can bathe and shower at 24 hours, he or she may not actually be interested in doing so. If a patient has an abdominal drain in place, bathing such that the drain site is submerged should be avoided until the drain is removed.
3. Activity: For the patient who has an outpatient ventral hernia repair, walking, climbing stairs, and lifting up to 10 pounds are allowed for the first 2 weeks. We repair these defects with a mesh placed in the peritoneal cavity and anchored at the periphery with interrupted suture and spiral tacks. For the first 2 weeks, the strength of the repair depends on the sutures and for that reason lifting is restricted. From 2 to 4 weeks, increased activity and lifting are per- mitted as described with inguinal hernia repair. At 4 weeks the patient can often resume normal activity and lifting. The level of incisional pain and abdominal wall discomfort should be the gauge to temper the patient’s activity. For patients with ventral hernias larger than 5 cm or multiple hernias who spend 1 or 2 days in the hospital, the return to normal activity is likely to take longer. We encour- age walking the evening of surgery and recommend progressive walking from the first day on. Lifting is limited to 10 pounds, and at 4 weeks we allow the patients to lift as they did preoperatively.
4. Exercise/sport: For the first month exercise is limited to walking and stair climbing. After 4 weeks, those patients who had small hernias and an uncom- plicated course may gradually increase their activity to include running and weight lifting. Patients who have had difficult repairs, or multiple, large, or recur- rent hernias, probably should avoid contact sports altogether.
5. Driving: Resumption of driving depends on mobility, reaction time, and the patient’s ability to respond to any road hazard. For most patients who were driving before the operation, their reflexes and faculties will be back to baseline by 1–2 weeks. As mentioned above, the patient should not begin driving if the physical activities required (movements of feet, arms, and upper torso) are painful.
6. Return to work: From a wound healing and surgical point of view, patients with smaller ventral hernias could return to work as early as 7–10 days postop- eratively. Whether they do return to work early is a multifactorial decision mod- ified in large part by the patient’s motivation and energy level in the postoperative period. Patients with office jobs and limited physical activity certainly could return to work at 2 weeks, at least on a part-time basis.
Patients with large or multiple hernia repairs who spend several days in the hospital sometimes need a longer recovery period and may require 3–4 weeks before returning to work.
The laparoscopic approach decreases the incidence of wound complications after hernia repair. This may shorten the hospital stay and recovery time for these patients and may also allow them to return to work sooner than with the tradi- tional open approach.
D. Laparoscopic Antireflux Procedures:
Fundoplications
1. Diet: These patients are frequently kept in the hospital at least 1 night after surgery. There are two popular philosophies to which surgeons ascribe with regard to feeding. One practice is to obtain a barium or gastrograffin swallow- ing study to rule out an esophageal injury before feeding the patient. This study
is usually performed on the first postoperative day, and if the study is normal, the patient is started on a liquid diet. The other school of thought determines suitability for feeding on a clinical basis, and patients may be started on liquids the night of surgery.
Often the combination of fundoplication and postoperative swelling may make certain solid foods difficult to swallow. We warn our patients to expect a small degree of postsurgical dysphagia. We instruct them to be certain to eat small bites of food and to chew well. We also caution them against eating breads and dry meats such as turkey or roast beef during the first postoperative week.
2. Bath/shower: Wait 24 hours for the incisions to seal and then the patient may shower or bathe as desired.
3. Activity: As with laparoscopic cholecystectomy, abdominal wall pain and incision discomfort determine the level of each patient’s activity. Walking and stair climbing are encouraged, and lifting 5–10 pounds is allowed as tolerated.
Usually abdominal discomfort is the limiting factor, but by 4 weeks the patient should be back to normal preoperative capabilities.
4. Exercise/sport: There is no reason not to participate in noncontact sports such as running or swimming after 1–2 weeks. Again, incision discomfort should be the guide by which activities are reintroduced. It seems prudent to avoid weight lifting and contact sports for the first 4 weeks to allow the cannulation sites to fully heal.
If the patient had a particularly large hiatus hernia, we typically ask them to refrain from any lifting whatsoever during the first month following surgery. We worry that strenuous activity that would result in Valsalva maneuvers might cause the hernia to recur in the early postoperative period.
5. Driving: Resumption of driving depends on mobility, reaction time, and the patient’s ability to respond to any road hazard. For most patients who were driving before the operation, their reflexes and faculties will be back to baseline by 1–2 weeks. As mentioned above, the patient should not begin driving if the physical activities required (movements of feet, arms, and upper torso) are painful.
6. Return to work: The decision to determine when to return to work depends on the type of work and how physically demanding it is, patient moti- vation, energy level, and length of sick time allowed by the employer and/or the insurance company. From a physiologic and anatomic point of view, it is possi- ble and safe for a person with a nonlifting job to return to work after 1 week.
As with many other major surgical procedures, fatigue is not unusual and there- fore resumption of work on a part-time or light duty basis is appropriate. We commonly recommend longer periods off work (up to 4 weeks) for those patients who have more strenuous jobs, such as construction workers or truck drivers.
E. Gastric Bypass/Bariatric Procedures
1. Diet: The schedule for feeding a patient varies from surgeon to surgeon.
Patients with a gastrojejunostomy frequently have a barium or gastrograffin swallowing study before starting a diet. Patients are then advanced from clear
liquids to full liquids over the next 3–5 days and then switched to regular diet eaten in small amounts several times a day. This schedule is also often followed for patients who have had a vertical banded gastroplasty or a laparoscopic gastric band placed. In each case the pouch is quite restrictive, and therefore in the first weeks eating small amounts several times a day is recommended. Because of the limited size of the gastric outlet in these patients following surgery, we caution them against eating breads and dry meats such as turkey or roast beef during the first 4 postoperative weeks. Food must be cut into small pieces (about the size of a pencil eraser) and chewed well.
2. Shower/bathing: Wait 24 hours for the incisions to heal and then the patient may shower or bathe. If an abdominal wall drain is in place, wait until the drain is removed before bathing.
3. Activity/lifting: Pain and incisional discomfort are the usual limitations to postoperative activity. Walking and stair climbing are encouraged. Many of these patients have significant comorbidities such as degenerative joint disease, dyspnea on exertion, and hypoventilation syndrome. Consequently, their post- operative activity will be less than that of patients after cholecystectomy or inguinal hernia repair. Nonetheless, the risk of incisional hernia is small, and walking and stair climbing are encouraged.
4. Exercise/sport: These patients have not engaged in running, contact sports, or active exercises because of their obesity preoperatively, and partici- pation in sports thus will not be an immediate goal or question in the postoper- ative period. Walking, stair climbing, and swimming are the preferred forms of exercise for these patients, and competitive sports will be an option down the road as their weight gets closer to the ideal.
5. Driving: Resumption of driving for these patients will depend on their driving skills before the operation, their mobility and response time, and their overall energy level. General guidelines here are a bit difficult, and we would recommend that the doctor and the patient decide this on a case-by-case basis.
6. Return to work: The decision to return to work will largely be determined by the patient’s energy level, the activity and mobility of the individual, disabil- ities caused by comorbid conditions, and the type of work the patient performs.
White-collar workers often are able to return to work within 2–3 weeks if their disabilities are limited to hypertension and diabetes. If patients were significantly disabled before their operation, their fitness for the workplace in many cases will improve as they lose weight and the comorbid problems become less of a burden.
These patients experience more fatigue in the first month postoperatively, and it may be necessary for them to start work on a part-time basis.
F. Splenectomy
1. Diet: After laparoscopic splenectomy, most patients resume a liquid and then a solid diet within a day or two. The limiting factors will be nausea or post- operative ileus, which occurs in 5%–10% of patients. Because there is no intesti- nal anastomosis, there is no concern about intestinal leak and, therefore, patients
can more rapidly resume their normal eating habits. In addition, patients can take their preoperative medicines right away. We generally hold anticoagulation for 24 hours.
2. Bath/shower: Wait 24 hours for the incisions to seal and then the patient may shower or bathe as desired.
3. Activity: We encourage walking and allow stair climbing. The amount of activity is generally determined by any incisional pain or abdominal discomfort that the patient may experience. Moderate lifting of 5–10 pounds is not harmful, and most patients can easily resume preoperative activity by 2 weeks.
4. Exercise/sport: Walking is preferred to running for the first 10–14 days, but running would not interfere with healing if this activity is not painful. Some patients require a longer incision for extraction of the specimen in certain disease states. In these patients we restrict weight lifting and contact sports for 4 weeks;
after 4 weeks, full activities can be resumed as tolerated.
5. Driving: This decision should be individualized for each patient. There are many factors to consider, including the patient’s age, mobility, reaction time, and ability to respond to any road hazard or emergency. For most patients who were driving before the operation, their reflexes and motor skills will be back to baseline by 1–2 weeks. As for the other operations discussed above, the patient should not begin driving until the physical activities required (movements of feet, arms, and upper torso) are not painful.
6. Return to work: After splenectomy, the patient’s general medical condi- tion and indications for the operation are the most important determinants of when the patient returns to work. These patients often suffer from chronic illness and have serious medical conditions that preclude work before and after surgery.
However, if the patient is interested in working, and feels well, then return to nonstrenuous work can be expected 2 weeks after splenectomy.
G. Laparoscopic Colectomy
1. Diet: In most cases after colectomy, the patient will have either an anas- tomosis or a colostomy. As with open surgery, there is a postoperative ileus that must resolve before we feed these patients. The ileus usually resolves within 1 to 4 days. The usual guidelines for diet and feeding after open colectomy apply here as well.
2. Bath/shower: From the wound healing perspective, patients can shower 24 hours after surgery.
3. Activity: Walking the evening of surgery is allowed and certainly encour- aged. Incisional pain and abdominal discomfort will largely determine how much a patient walks. Many of these procedures require incisions of varying length to facilitate specimen removal. Moderate lifting of 5–10 pounds is not harmful, and in an uncomplicated case the patient can usually resume normal daily activity within 1–2 weeks.
4. Exercise/sport: Walking is preferred to running for the first 10–14 days, but running would not interfere with healing if this activity is not painful. We
tend to restrict weight lifting and contact sports for 4 weeks in most patients;
after 4 weeks, normal activity and exercise are encouraged on a gradual schedule.
5. Driving: Resumption of driving depends on the patient’s energy level, mobility, reaction time, and ability to respond to any road hazard as well as their general condition. For most patients who were driving before colectomy, driving should be possible in 3–4 weeks. The patient should not begin driving until the physical activities required (movements of feet, arms, and upper torso) are not painful.
6. Return to work: After colectomy, the patient’s general medical condition is the most important determinants of when the patient returns to work. These patients often suffer from chronic illness and have serious medical conditions that preclude work before surgery. If the patient is interested in working, feels well, and has a good energy level, resumption of a nonlifting job or light duty work within 2 weeks after colectomy is reasonable.
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