Having major surgery
Major surgical procedures are carried out under general or regional anaesthesia.
Major surgery always takes place in hospital and usually involves a procedure performed on tissue deep inside the body. For example, surgery to remove a section of intestine, implant an artificial hip, or bypass a coronary artery would be considered major surgery (see Types of surgery).
Before you undergo a major surgical procedure, your doctor will discuss with you why surgery is necessary, exactly what the procedure involves, where the operation will take place, and how long it will take. You will be fully informed about possible risks associated with the operation, and you will be asked to sign a consent form to say that you understand the risks and agree to surgery.
Before the procedure is performed, your general health and fitness for surgery will be assessed. On the day of the operation, you will be prepared for surgery and given an anaesthetic. Usually, major surgery is performed under general anaesthesia (see Having a general anaesthetic). However, an increasing number of procedures are now carried out under regional anaesthesia (see Having a regional anaesthetic), in which you remain fully conscious but free of pain. A sedative may be given along with regional anaesthesia to help to keep you calm and reduce anxiety. The type of anaesthesia you have depends largely on the nature of the procedure, but your general health and age may also play a part.
After the operation has been completed, there is a recovery period. For most major surgical procedures, a stay in hospital of several days is required. However, some relatively uncomplicated procedures, such as female sterilization, are sometimes carried out as day surgery. This is particularly likely if the procedures are performed using modern minimally invasive techniques (see Endoscopic surgery).
Your doctor will be able to advise you on how long it will take for you to recover from your operation. There may be particular practical issues that you wish to clarify with the doctor. For example, you may want to check whether further treatment will be needed after the operation and how long it is likely to be before you are able to carry out your normal day-to-day activities.
Preoperative assessment of major surgery
Before you undergo a major surgical procedure, you will be given a preoperative assessment. The main purpose of this assessment is to find out whether you have an underlying medical condition, such as heart disease, that may require special precautions during the operation in order to minimize the risk of complications developing.
During the preoperative assessment, a doctor reviews your medical history and performs a physical examination. Routine tests, such as blood tests, will also be carried out, together with any other investigations that may be needed because of your age, general health, or underlying condition.
You will also be seen by an anaesthetist, who checks your suitability for anaesthesia, discusses how the anaesthetic will be administered, and answers any questions you may have.
Medical history and examination
You will be asked about your current condition and about other serious illnesses or allergies you have experienced in the past (see Medical history). You will also be asked about any medications you are taking because these may affect the safety of the surgery. You will then be given a full medical examination, during which the doctor will listen to your chest and back with a stethoscope (see Physical examination), to help to identify any underlying medical conditions that may increase the risk of complications occurring during or following the operation.
You may have a number of routine tests, many of which require a sample of blood or occasionally urine to be taken. Blood tests usually require no more than two or three small tubes of blood to be withdrawn through a single needle (see Blood samples). The most common blood test measures the level of haemoglobin in your blood (see Blood cell tests). Haemoglobin is an oxygen-carrying pigment found in red blood cells. If you lose a small amount of blood during surgery, it is important that your body still has adequate reserves of haemoglobin to compensate. Your blood group will also be checked (see Blood typing). A sample of blood may be saved for cross-matching against blood from the blood bank if you need to have a blood transfusion during surgery. The levels of certain chemicals, such as urea and salts, in your blood may be measured because they reflect the function of internal organs such as the kidneys (see Routine blood chemistry).
Other presurgical investigations
Depending on the outcome of your initial physical examination, your doctor may decide that other investigations are needed before you undergo surgery. For example, if your medical history suggests that you may have heart disease, your doctor may arrange for an ECG to assess the condition of your heart and make a diagnosis. If there is a possibility that you have a heart or lung disorder, a chest X-ray may also be performed. The results of these tests may influence how the surgery is carried out and the level of monitoring that is required during the operation. In some cases, these initial test results indicate the need for further investigations, such as exercise testing, which evaluates the flow of blood to the heart while a person is at rest and during the physical stress of exercise.
Preparations for major surgery
On the day of your surgery, you will be prepared for the operation and given premedication drugs. You will then be given the anaesthetic.
You should not eat or drink for at least 6 hours before an operation under general anaesthesia. If you have food in your stomach, there is an increased risk of vomiting while you are unconscious. If the acidic contents of the stomach are inhaled, serious damage to your lungs may result. You may also need to fast if you are having a regional anaesthetic in case it becomes necessary to give you a general anaesthetic during surgery.
If there is a particular risk of infection occurring during the operation, such as bacteria spreading from the intestine during intestinal surgery, a course of antibiotics may be prescribed. These may be given initially by injection. An hour or two before your operation, you will be asked to remove all jewellery and to change into a surgical gown. You will be asked to remove dentures, if you have them, or to point out loose teeth or crowns, which could be damaged when the breathing tube for anaesthetic gases is inserted. If a surgical incision is to be made in an area of skin that is covered with hair, the area may be shaved to make the skin easier to clean. The surgeon may mark the skin over the site of the operation to indicate where the incision should be made.
An hour or so before your anaesthetic, you will be given premedication drugs to help you to feel calm and to dry mucous secretions. These drugs may be administered by injection or by mouth. A nurse will then take you to the operating theatre.
When you arrive in the operating theatre, you will be given an anaesthetic. For longer operations carried out under general anaesthesia, the anaesthetic is given in two parts. First, an anaesthetic is injected into a vein on the back of your hand. Although this injection induces anaesthesia rapidly, it is not long-lasting. Second, inhaled gases are given to maintain unconsciousness. For shorter operations, a single injected or inhaled anaesthetic may be used.
The initial anaesthetic drug is injected into a thin plastic tube called a catheter. This tube is inserted into a vein either in the back of your hand or in your arm, and the anaesthetic drug causes almost immediate loss of consciousness.
The anaesthetist then inserts a breathing tube, called an endotracheal tube, through your mouth and down into your trachea (windpipe). The tube is connected to a ventilator, which regulates the speed and depth of breathing throughout surgery. You will be given a mixture of gases to breathe, including oxygen and an inhaled anaesthetic. You will also be given a drug through the catheter that relaxes your muscles and therefore makes it possible for the surgeon to cut and move muscles easily. By doing this, the surgeon can obtain a clear view of the operating area.
If you are having a regional anaesthetic, the anaesthetic drug is given by injection. The site of the injection varies according to the procedure that is to be performed, and for some types of regional anaesthesia, such as epidural or spinal anaesthesia, the skin around the injection site will be numbed first with a local anaesthetic.
In the operating theatre
As soon as you are anaesthetized, the surgeon or assistant surgeon uses an antiseptic solution to clean the appropriate area of your skin. The solution used may leave pink or brown stains on the skin for a short time after the operation. The remaining nonsterile parts of your skin are covered with sterile drapes, and the procedure is then carried out.
When the procedure is completed, the wound is closed up (see Rejoining tissue) by the surgeon. For some types of wound, you may have internal stitches as well as those that are visible on your skin. If you have been given a general anaesthetic, the proportion of anaesthetic gases you are breathing will be reduced and the proportion of oxygen you are given will be increased to allow you to wake up.
In the recovery room
As soon as you show signs of breathing on your own, the anaesthetist will remove the endotracheal tube. You may hear someone telling you the operation is over, but you will probably wake up only briefly. You will then be moved to the recovery room. If you have had a general anaesthetic, the recovery room is probably the first place that you will remember after the operation. For the first hours after a major operation, your temperature, blood pressure, and pulse are checked frequently. When you are taken back to the ward, usually when you are fully awake, these checks are repeated, but less frequently.
Some major surgery requires intensive nursing care afterwards, and you may be transferred to an intensive care unit rather than taken directly back to the ward. You will be transferred to the ward when you are no longer dependent on specialized equipment and medical personnel.
Back to the ward
After major surgery, you will be transferred to the ward so that you can be monitored and given any further treatment that you may need. Postoperative monitoring is carried out in order to identify any complications as early as possible. If necessary, you will be given pain relief. Generally, the more extensive the operation, the longer it will take for you to recover. Usually, your recovery is faster and complications are less likely to occur if you start moving around as soon as possible after the effects of the anaesthetic have worn off.
If you have had a general anaesthetic, you are likely to remain drowsy for a number of hours. After regional anaesthesia, you will not experience the drowsiness that normally follows general anaesthesia. However, the numbing effects of a regional anaesthetic usually take several hours to wear off.
Treatment and monitoring
You may be attached to tubes and equipment that monitor your condition or help you to perform particular bodily processes. For example, you may be attached to an ECG machine that monitors your heart function. You may have a urinary catheter if surgery has involved the bladder or nearby organs, such as the prostate gland. The catheter enables medical staff to monitor the amount of urine that you produce. An intravenous drip may be placed in your arm or the back of your hand to deliver fluids and medication if necessary. Fluids help to prevent you becoming dehydrated until you are able to eat and drink normally. After certain procedures, there may be a tube called a drain coming from a small hole in the skin near the surgical wound. This tube is often attached to a vacuum bottle and allows excess tissue fluid or blood to drain away from the operation site. It is usually removed after a few days. You may also have a tube called a central line coming from the side of your neck or just below your collarbone. This tube is held in place by stitches and is used to monitor your fluid balance and blood pressure and to give you extra fluids or drugs if these are needed. This tube will be removed as soon as continuous monitoring and fluids are no longer necessary.
Pain relief of major surgery
You may not feel much pain when you wake up because of the effects of the drugs you have received during anaesthesia, and because the surgeon may inject a local anaesthetic into the edges of the surgical wound. After a few hours, you may become more uncomfortable and require painkillers. These drugs may be administered orally or by injection, depending on the drug, the severity of your pain, and your ability to absorb the medication. You may be able to administer your own painkillers in small, safe doses as often as you need to using a patient-controlled analgesic pump attached to a tube that is inserted into a blood vessel in your arm. This type of pump has a built-in device to prevent you from receiving too much medication.
Some major surgery may necessitate other treatments to prevent complications. For example, blood clots may develop in the legs (see Deep vein thrombosis) if you are immobile for long periods of time. These clots may break off and travel to the heart or lungs, which may be life-threatening. If clots are likely to form, your doctor will prescribe injections of a drug that reduces blood clotting (see Drugs that prevent blood clotting), which are usually given into the skin of the abdomen. You may also need to wear support stockings for a few days until you are fully mobile.
If you have had an operation on an infected area such as an abscess, you may be given antibiotics. Depending on the type of operation you have had, you may be offered physiotherapy or other treatment while in hospital to help you to return to full mobility.
Leaving the hospital
You will be discharged from hospital when you no longer need close monitoring or special treatment. You usually need to be eating and drinking normally without the aid of tubes and to be able to pass urine without a catheter. The medical staff need to be satisfied that you have someone to accompany you home and that you will be adequately looked after if you are unable take care of yourself. Home nursing (see Home care) may need to be organized in advance. If you require special aids, such as a bath lift, you may be assessed by an occupational therapist (see Occupational therapy) before you are discharged from hospital.
Before you leave hospital, you will be provided with any medication that you need, and a follow-up appointment will be made to check on your progress and, if necessary, to remove stitches.
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