What to expect after surgery

Nena, a 46-year-old accountant, had a total hysterectomy (surgical removal of the uterus) for a large myoma a week ago. She called me up because of constipation for three days, and she was worried about “bursting her stitches” if she strained in the toilet. I encouraged her to take in more fruits and vegetables, plus a good dose of water. After 24 hours she happily reported that she finally had her bowel movement, and felt so much better.

What can one expect after a major surgery like hysterectomy?

First we need to understand that the body registers the surgery with its incisions and removal of organs as a “harmful” stimuli, an “invasion.” It reacts by summoning the nervous and endocrine systems, including the immunologic system to release hormones to protect itself, using up its stores of reserved energies to “fight back.” This is the so-called “catabolic state” after surgery. During this state, the patient feels weak, sleepy, easily tired, and these are all a natural protective mechanism where the body recuperates, stores up new energy again to regain a healthy equilibrium.

During the immediate post-operative period, which is the first 24 hours after surgery, you will be asked to lie flat on your back for at least 6 hours if the anesthesia is regional (e.g. spinal), avoid food to rest the stomach and the intestines, and avoid talking to prevent air swallowing which might lead to bloatedness and abdominal pain. You will have an intravenous line which will provide you with the needed water, glucose and electrolytes while you cannot eat.

Pain medications will be through your intravenous line; more often than not there will also be another pain medicine as a stand-by in case the pain becomes intolerable in spite of the IV drip analgesic. In epidural anesthesia where a fine wire-like catheter is inserted at the back, the analgesic, which is usually morphine, is injected through the port carried over to the shoulder. To monitor your vital signs, nurses will come and take your blood pressure, cardiac and respiratory rates, and temperature in designated times. To make sure that your kidneys are functioning well, an indwelling urinary catheter is inserted to monitor your urine output.

On the first day after the surgery, you will be encouraged to move from side to side, or, if you can tolerate it, sit up in bed. Don’t hurry though. Listen to your body. The first day is usually “pain-confrontation” day, where you will realize the full force of the body’s reaction to the surgery, but do make an effort to at least move in bed, or sit up.

Moving about has a lot of advantages. This will encourage movement of the small intestines, and ultimately the large intestines will start to “wake up.” When the large intestines start functioning, gas will be expelled, and this is one sign that you can start having food and water. Doctors will have second thoughts giving you the okay for taking in food and water if there is no passage of gas for fear of post-operative ileus, where the intestines become paralyzed, and things ingested simply stay in the GI tract and add to gas formation, abdominal distention, and bloating. So don’t be disappointed if you are not yet allowed to eat or drink during the first 24 hours after surgery. Sodas or milk are likewise best avoided, because they easily form gas inside the intestines. 

If urine output is adequate, the urinary catheter will be removed after 24 hours, so you can freely move about some more. The IV line is usually removed during the second post-op day, unless your doctor thinks there is a reason for it to remain: you need more hydration, or continuation of IV meds. Likewise, the epidural catheter will also be removed at this time, and medicines will be taken by mouth. Walk around your room. When you have moved your bowels, you are ready to be discharged from the hospital, and rest at home.

You will easily feel tired and need some pampering. This is no time for wonder-woman feats, so do not be afraid to ask for help for housework at home. From time to time, there will be pain, which is the body’s natural reaction to the surgery. During the first week too, after a hysterectomy, there might be some vaginal staining, from specks of red to pinkish brown, this is normal, as sutures involve the upper vaginal canal. Bleeding of course is not normal, and you should seek medical consult immediately if this happens.

The wound, which is usually closed by sutures that are hidden under the skin, will need minimal care. Change the covering gauze often, at least once a day, or more often, if soiled. Some doctors will also advise against taking a full bath, or washing the fresh wound until after the follow-up. Continuation of oral antibiotics, or analgesics as needed, or even an iron tablet at home are advised. These will all help with the wound healing. After a few days the wound will start to heal and contract and might feel itchy. Do not rub or scratch it. At times gels or creams are recommended for good wound healing. Some skins though, have a tendency for keloid formation, and no amount of gels or creams can prevent them. After some time though, the keloid will flatten out and become less dark.

The doctor will ask you to follow-up after a week to check the wound, and also the vaginal vault, so an internal examination is done.

When can you go back to work? We usually recommend 45 to 60 days of rest at home after a hysterectomy. How about exercises? For light exercises, probably after 45 days; low impact aerobics, 60 days. These are all approximations, so ask your gynecologist. When the vaginal vault has sufficiently healed, after around 60 days, sexual relations can be resumed.

Another frequently asked question is whether you will still menstruate after the procedure. The answer is no. Menstruation comes from the lining of the uterus called the endometrium, so when the uterus is removed, as in a hysterectomy, no menstruation will occur. How about the fear of menopausal symptoms like drying out of skin, hot flashes and sweating and “looking old?” These will all depend whether your ovaries were also removed.

The ovaries are two ovoid organs, the right and the left, at both sides of the uterus suspended at the end of the fallopian tubes. A hysterectomy may be done on a young woman (below 40 years old) for uterine problems like myomas; in these cases, the ovaries are usually left behind so the woman can continue to benefit from the hormones secreted by the ovaries (mainly estrogen), so no menopausal symptoms are felt. The gynecologist will inspect the ovaries very carefully during the operation and decides whether to leave them behind or not. For women between 40 to 50 years old, closer discussion is needed whether or not to remove the ovaries. An open mind is encouraged, and do speak to your gynecologist for any doubts. —KG, GMA News

Dr. Alice M. Sun-Cua is an author and practicing obstetrician-gynecologist at the San Juan de Dios Hospital in Pasay City.