Pre-operative Instructions

 

Once a patient has been deemed an appropriate surgical candidate for a bariatric procedure, they must follow certain protocols in preparation for surgery:

 

a.    Pre-operative tests requested by your surgeon must be completed. Most commonly, your surgeon will request the following:

A.    Full physical examination: To be completed by patient’s primary care physician within a few weeks of the surgical procedure.

B.    Chest X ray and EKG: recently taken, will be required.

C.    Lab tests: including: CBC, CMP, PT-PTT, UA.

D.   Upper Endoscopy: is recommended in patient with a fanily history of grastric cancer and treated GERD.

E.    Cardiac Clearance: Patients over 45 years old, diabetic and patient with a cardiac history will be required to undergo a full cardiac clearance.

 

 

b. Informed Consent Protocol: All patients usually meet with their surgeon a second time prior to the procedure. This meeting takes place in the office and is called “the completion of the informed consent protocol.” It is usually a quick meeting to verify the patient is ready for the surgery.

 

c. Pre-Operative Diet: Start your pre-operative liquid diet 2- weeks prior to surgery as instructed. By the surgery date, most patients have lost an average of 9 to 10 pounds.

Start your CLEAR liquid diet, 2-days prior to the procedure.

Follow the instructions given by your coordinator.

 

d. Hospital Admission Information: Prior to surgery, obtain all admission information for the day of surgery. You’ll want the time of your surgical procedure and you’ll need the time you must arrive the morning of the procedure.

 

e. CAUTION Regarding Blood Products: Patients who will not accept transfusion of any form of blood products [Jehovah Witnesses, etc.] must notify this office as soon as possible. Special precautions need to be arranged.

 

If you have any specific questions, please contact our Bariatric clinical Coordinator. The following instructions will prepare you for your surgical procedure.

 

You will be given an admission time and an anticipated surgery time. Please be on time, as you could significantly delay your surgery. (Note: Your surgery time is an anticipated time, not a guaranteed time. In some cases, delays may occur as previous surgical procedures may take longer than planned. Please be patient and courteous to our hospital staff should your procedure be delayed.)

 

If feasible, you should walk at least one mile or more per day beginning a few weeks prior to the procedure. If walking is not feasible, you should perform leg exercises several times a day. These maneuvers are essential for the prevention of intra- and postoperative formation of blood clots in the legs and pelvic veins [Deep Vein Thrombosis] which could generate a blood clot to the lungs [Pulmonary Embolus].

 

Day of Surgery

 

• Arrive at the hospital on time.

• You will be admitted by our nurse. Once your admission work-up and check is completed, you will be asked to change into a hospital gown and will be transferred to our Preoperative Holding Area. At this point, your family will be asked to wait in the Surgical Waiting Room or Lobby.

• In the Preoperative Holding Room, you will meet your assigned anesthesiologist and your operating room nurse. Your surgeon will perform the final preoperative check.

• An intravenous line may be started then or in the operating room. You will receive preoperative medications to make you feel at ease and relaxed.

• For some patients, special monitoring lines will be inserted as ordered by your surgeon, such as arterial lines or Cardiac Monitoring Catheters [Swan-Ganz Catheters, Central Lines, etc.]. In addition, you may be given certain respiratory medications or an inhaler to maximize your respiratory function.

• Pneumatic compression stockings or bandages will be placed on your legs to prevent the formation of blood clots.

• You will be transferred to the operating room by the nursing staff.

 

Awakening from General Anesthesia

 

• Although  many patients claim they do not remember this stage of their hospital stay, all patients wake up gradually in the Recovery Room.

• Some patients may wake up with an endo-tracheal tube or “breathing tube” in place. In that case, a respirator breathe for you, and it is important not to fight the breaths administered by the machine. The breathing tube will be removed as ordered by the surgeon.

• You may not drink or eat anything.

• You can move in bed at will and if you experience any pain, ask the nurse for medication.

• You will feel normal pressure from the pneumatic compression stockings on your legs.

• You will have an abdominal drainage [tube coming out of your stomach].

• Within a few hours, your surgeon will decide if you will be transferred to the Intensive Care Unit or to the Surgical Floor. If you are transferred to the Intensive Care Unit, you will be given detailed instructions.

 

Transferring to the Surgical Floor

 

Surgical floors are specifically designed to care for bariatric patients. Occasionally, these units will be full, and you may be transferred to a different nursing unit.

 

You will be admitted to your private hospital room by your assigned nurse. Your nurse will give you a set of instructions for the day. In addition, you should remember the following.

• Your pneumatic compression stockings are to remain in place at all times when in bed.

• You will get drinking instructions from your nurse on the floor.

• You should get out of bed and walk as often as possible, or exercise your legs as instructed. The more you ambulate, the better for you. Each patient is asked to walk at least 20 laps a day around the South nursing stations.

• Use your incentive spirometer as often as possible, [at least once every half hour].

 

Postoperative Days # 1 

 

• The same guidelines apply. Again, you need to walk as much as possible.

• You are drinking fluids. Start with small sips of water, and wait a minute or two between sips. Your nurse will give you a sipping cup to help you gauge your intake.

• You will be started on a clear-liquid diet. The newly- formed gastric pouch or tube [sleeve] is about the size of a walnut and cannot tolerate more than a sip of fluid at a time until it empties, so do not drink too much at once for the first two weeks. The gastric pouch will remain fragile during that time.

• In addition, for the first week after surgery, it will be almost impossible to take in a significant amount of calories, but your only concern during that time is drinking enough fluid [at least one liter per day]. The best way to assure a sustained, adequate intake of fluid is to purchase 1 liter of mineral water and finish it every day. The 1-liter-of-fluid-per-day requirement includes all fluids [ protein shakes, juices, etc.].

• The hospital staff will begin to bring you clear liquids and soon, full liquid meals. You do not have to finish each meal. Use small, separated sips. Wait between sips. Stop drinking when you feel full.

• Your intravenous line will soon be removed, and you will be started on oral pain medication.

• Patients are discharged mid-day on a full liquid diet consisting of carbohydrate (sugar) and fat-poor liquid. No solid food should be consumed.

• Your surgeon will either remove the abdominal drain before you go home or a few days later in his office.

• You will need someone to drive you home.

 

 

Hospital Discharge Instructions

·         Condition on Discharge: You can only be discharged from the medical center, if you are drinking enough fluid, walking well, and are pain free.

·         Medications: You should resume all your routine medications.

Diabetic and hypertensive patients will need to adjust the dosage of their medication. Most of these patients will be discharged on “no medications” and should see their primary care physicians within a week. For other cases, the nursing staff will give specific instructions.

·         Abdominal Drain: This office routinely places a so-called “Blake Drain” in all patients undergoing a Laparoscopic Gastric-Bypass with Roux-en-Y Limb. The removal of this drain is a surgical decision made by your surgeon. Some patients will be discharged with the drain in place. Proper instructions will be given at that time by the nursing staff.

·         Leaving the Medical Center: You cannot drive on the day of your discharge. Make sure you take your Incentive Spirometer with you and use it at home for the first week.

 

·         For Patients Living outside of the Greater Los Angeles Area: Patients having to drive for more than 30-minutes in a car must take the following precautions:

1.    Stop the car every 30-45-minutes and walk for 10- minutes.

2.    Move your legs frequently while sitting in the car.

 

When to call your surgeon:

o       Vomiting.

o       Fever over 101F.

o       Pain: increased or unusual.

o       Shortness of breath.

o       Color change of drainage from abdominal drain        [if a drain is in place].

o       Any unusual problem.

 

Post-operative Instructions – Protocol

·         Medications/Supplements: CAUTION: All patients who underwent a laparoscopic gastric bypass Roux Y are required to take supplements . There are no demonstrable untoward effects from taking the following medications or supplements:

 

o       Multi-vitamins with Iron:  twice per day.  We recommend chewable Centrum Completeä. 

o       SupplementalB12 sublingual: once per week.

o       Supplemental Calcium - twice per day.  We recommend calcium citrate.

 

o       For patients who underwent a Laparoscopic gastric bypass Roux Y or a Laparoscopic Sleeve Gastrectomy, Actigall or URSO™: as directed by your surgeon.  This is a bile thinning medication that we prescribe for our patients who still have their gallbladders after gastric-bypass.  This is a 6-month course.

 

·         Schedule for Follow-Up Appointments: Unless patients are experiencing difficulties, you will be seen in our office on the following schedule:

o       10 days after the surgical procedure.

o       Week 6:

o       3-months

o       6-months: End Actigall

o       9-months

o       1-year

o       After the first year, twice a year

·         Labs: will be done on the following schedule: 

o       3-months

o       6-months

o       9-months

o       1-year, and twice a year thereafter.

 

If you have any questions call our bariatric coordinator.