3. Preoperative Patient Instructions
Tracey D. Arnell, M.D.
A. Goals of Preoperative Patient Instructions
1. The goals of preoperative patient instructions are:
i. Patient education. Included in this is technical information as well as information regarding appropriate expectations. Patients with realistic expectations regarding issues such as pain, recovery, length of stay, and potential complications do better.
ii. To make patients aware of their risk factors. Involve patients in modifying risk factors that may decrease the risk of complica- tions. (To motivate patients to alter their behavior such that they impact on their risk factors.)
iii. To give specific instructions regarding bowel preparation, cessa- tion of diet and fluids, management of patients’ baseline medica- tions and special surgery-related medications as well as day of surgery instructions.
B. Patient Education
1. Options. Once the decision to perform surgery is made, the surgical alternatives should be presented to the patient. In regard to surgical approach for abdominal procedures, traditional open and laparoscopic methods, including the advantages and disadvantages of each approach, are discussed.
i. Laparoscopic resection
1. Advantages. There are increasing data that laparoscopic methods are associated with advantages other than smaller, more cosmetic scars. These include a more rapid return to normal activity, a minor decrease in hospital stay, and a decrease in wound infection and subsequent hernias.
Recent evidence also suggests that laparoscopic techniques are associated with significantly better preserved immune function as compared with open surgery.
2. Disadvantages. Generally, operative times are significantly longer, although the differences decrease with increasing surgeon experience. Cost has traditionally been thought to be higher, although recent reports refute this. Availability of surgeons with adequate advanced laparoscopic training and experience is a limiting factor.
ii. General considerations
1. Surgeon experience. Most studies support a learning curve regarding operative times, conversion rates, and complications.
2. The possibility that an operation will need to be converted to an open procedure. Patients must be aware there is always a potential for conversion to an open procedure. It is not rea- sonable or honest to “promise” or guarantee patients that their operation will be completed laparoscopically. The conversion rate varies depending on the procedure, surgeon experience, body habitus, and pathology (Table 3.1).
2. Technical information
i. There are many resources for general information regarding laparoscopic surgery including the Internet, patient pamphlets, and videos. In addition, most patients appreciate a more detailed explanation of the specific procedure to be carried out; for example, the number and location of port incisions as well as the need for an extended or additional incision in the case of hand- assisted or laparoscopic-assisted operations may be mentioned.
3. Expectations
i. Pain. Although laparoscopic surgery is associated with decreased pain, and a decreased need for narcotics, patients should under- stand there will be pain and discomfort following surgery.
ii. Diet. Depending on the procedure and the surgeon, the diet may be resumed immediately following surgery or one or several days later. In regard to intestinal surgery, most studies suggest that an oral diet is tolerated 1 to 2 days earlier after a minimally invasive procedure than after the equivalent open procedure. The extent to which the surgeon’s expectations and bias impacted the postop- erative management and, possibly, the short-term recovery of patients in these studies is not clear.
iii. Hospital stay. Most published series report shorter length of stays for patients undergoing laparoscopic surgery. For intestinal surgery, the difference has not been as great as noted for proce- dures such as splenectomy and nephrectomy. Patients should understand that except for planned outpatient procedures (e.g., hernia) a hospital stay is generally required.
Table 3.1. Reported conversion rates.
Procedure Conversion rate
Antireflux wrap <4%
Urologic 1%–6%
Splenectomy <3%
Roux-en-Y gastric bypass 3%–10%
Colectomy 4%–23%
iv. Resumption of normal activities. Given the limited abdominal wall trauma and more rapid “in-hospital” recovery of laparo- scopic patients, it is not unreasonable to anticipate a more rapid return to normal activities. The heterogeneity of patients in regard to age and preoperative level of function as well as the lack of clear criteria defining “normal” activities for such a diverse pop- ulation makes this a difficult parameter to assess. Further, the time to full recovery will vary considerably depending on the specific procedure in question.
v. Conversion. All patients must be prepared for the possibility that it may prove necessary to make a large incision and utilize tradi- tional open methods. Therefore, only patients who are fit to undergo open surgery are candidates for laparoscopic surgery.
vi. Extended or additional incision. Depending on the particular pro- cedure, a larger incision may be needed for specimen retrieval (i.e., colectomy, nephrectomy). Patients should understand that for these “laparoscopic-assisted” procedures this incision is mandatory. Similarly, if there is a chance that hand-assisted methods may be used then it should be made clear that a larger incision will be required.
C. Risk Factor Modification
1. Pulmonary. Patients who smoke have an increased risk of pulmonary complications such as pneumonia and prolonged intubation. This is a result of a loss of cilia with decreased clearance of airborne particles and desquamated cells. Additionally, in patients with emphysema, there is a decrease in the functional reserve capacity. Patients should be urged to stop smoking because cessation of smoking for at least 1 week may decrease respiratory complication rates. The preoperative use of an incentive spirometer is also associated with fewer pul- monary complications.
2. Bleeding. There are many prescribed and over-the-counter medica- tions, vitamin supplements, and homeopathic medications that may alter an individual’s coagulation profile. If the medications are thought to be necessary for medical reasons (i.e., aspirin in a patient with a stroke or coronary artery disease), they may be continued with an understood slightly increased risk of bleeding. Otherwise, the risk of bleeding is not warranted and they should be stopped before surgery.
3. Deep venous thrombosis (DVT). Risk factors for DVT are covered else- where in this manual, but there are factors that can be modified in the short term. These risk factors include smoking, oral contraceptives, estrogen replacement drugs, and ambulation (the lack thereof ).
D. Specific Instructions
1. Bowel preparation. This subject is covered in Chapter 5, Part III.
2. Medications. For prescription medication, the following is a list of general recommendations.
i. Diabetes. Usually, the patient is advised to hold the daily dose of regular insulin and administer 1/4 to 1/2 the normal daily inter- mediate-acting insulin dose on the morning of surgery. Patients taking a bowel preparation may need to decrease their dosage of regular insulin as determined by glucose checks. Those with poorly controlled diabetes should be admitted for management of their diabetes.
ii. Aspirin. Unless required for medical reasons as previously described, aspirin and other platelet inactivators should be held for 7 days preoperatively.
iii. Coumadin. The physician in charge of the patient’s anticoagula- tion regimen should be consulted by the surgeon so that the indications for the coumadin be fully understood and so that an approach to stopping the coumadin can be agreed upon. One approach is to simply stop the coumadin 3 to 4 days before the surgery. Alternately, the patient is brought into the hospital several days preoperatively so that intravenous heparin can be given during the period when the coumadin has been held. As an alternative to in hospital I.V. heparin, subcutaneous injections of lovenox or other similar agents can be administered at home pre- operatively.
iv. Other medications. All other medications, including antihyper- tensives, thyroid replacement, and seizure medications, should be taken per the usual schedule.
E. Selected References
Carter JJ, Whelan RL. The immunologic consequences of laparoscopy in oncology. Surg Oncol Clin N Am 2001;10:655–677.
Lezoche E, Feliciotti F, Paganini AM, Guerrieri M, Campagnacci R, De Sanctis A. Laparo- scopic colonic resections versus open surgery: a prospective non-randomized study on 310 unselected cases. Hepato-Gastroenterology 2000;47:697–708.
Lezoche E, Feliciotti F, Paganini AM, et al. Laparoscopic vs. open hemicolectomy for colon cancer. Surg Endosc 2002;16:596–602.
Lujan HJ, Plasencia G, Jacobs M, Viamonte M, Hartmann RF. Long-term survival after laparoscopic colon resection for cancer: complete five-year follow-up. Dis Colon Rectum 2002;45:491–501.
Senagore AJ, Duepree HJ, Delaney CP, Dissanaike S, Brady KM, Fazio VW. Cost struc- ture of laparoscopic and open sigmoid colectomy for diverticular disease: similari- ties and differences. Dis Colon Rectum 2002;45:485–490.
Seshadri PA, Poulin EC, Schlachta CM, Cadeddu MO, Mamazza J. Does a laparoscopic approach to total abdominal colectomy and proctocolectomy offer advantages? Surg Endosc 2001;15:837–842.
Targarona EM, Gracia E, Garriga J, et al. Prospective randomized trial comparing conventional laparoscopic colectomy with hand-assisted laparoscopic colectomy:
applicability, immediate clinical outcome, inflammatory response, and cost. Surg Endosc 2002;16:234–239.
