Laparoscopic Bariatric Procedures


		Laparoscopic Bariatric Procedures

Laparoscopic Bariatric Procedures: Physician Section: Patients Instructions

DISCLOSURE DOCUMENTS: SECTION 10

Pre-operative and In-hospital Guidelines

Preoperative Preparation

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

You have been scheduled to undergo a bariatric surgical procedure or a “Laparoscopic Gastric Bypass with a Roux-en-Y Limb”.

	You will be required to sign a procedure-specific informed consent for the Bariatric Procedure. This consent must be signed and filed in your chart prior to the procedure.
	You will need to stop taking vitamins and nutritional supplements for two weeks prior to the procedure [including herbs, Ginko-biloba, St. Johns wort, etc].
	Bowel Preparation: To facilitate the surgeon’s ability to perform this procedure, the gastrointestinal tract must be cleaned and sterilized per the following Bowel Preparation Protocol:

Start a clear-liquid diet 48 hours prior to the procedure.

NPO Status: Nothing by mouth, as of midnight the day prior to the procedure. If instructed by your surgeon, you may take specific medications with a sip of water at 6 a.m. the morning of the procedure.

At noon the day prior to the procedure, drink one [1] bottle of phosphos soda [the entire bottle] as instructed.

At 8 p.m. the day prior to the procedure, self-administer 2 fleet enemas.

As ordered by your surgeon, take the following medications:

1 gm of Erythromycin Base and 1 gm of Neomycin at 6 p.m., 8 p.m.and 9 p.m. the day prior to the procedure. If the medications cause severe nausea, they should be discontinued, and you should notify the office staff.

	You must have a preoperative physical examination and clearance by your primary care physician or as arranged by your surgeon. If specific preoperative cardiac clearance has been ordered, it must be completed at least 24 hours prior to the surgical procedure.
	Preoperative lab work must be completed as ordered.
	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 endotracheal 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.

All patients will wake up with a nasogastric tube in place. This plastic tube is placed in your nose during surgery and goes into your stomach. This may be uncomfortable, but this tube needs to remain in place for your safety. Do not pull it out.

You may not drink or eat anything.

A Foley catheter or “urinary catheter” will be removed later that day or the next morning.

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 8 South East or 8 South West. 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 may not eat or drink, and your nasogastric tube is to remain in place for another day.
	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 10 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 and 2

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

Either the morning of postoperative day 1 or day 2, a “Hypaque Upper GI X-ray” will be performed. This test will confirm that the small, newly-created gastric pouch is intact and that no leaks are identified at the junction of the pouch and the small bowel [the gastroenterostomy]. If the test is normal, the nasogastric tube will be removed by your nurse.

The dye used for this x-ray will generate liquid stools within a few hours. This is normal and will stop within 24-48 hours.

Once your nasogastric tube is removed, you will be able to start 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 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.

At Home – General Instructions

The following are your guidelines when home. Keep in mind that all patients recover differently from this surgical procedure.

Diet: Full liquid only. You should have a minimum fluid intake of 1 liter per day [this includes all liquid]. No carbonated drink are allowed. You should start taking the liquid protein supplement of your choice. Although you may not be able to do so for the first week, you should eventually have a minimum intake of 40 gm. of protein per day. Some patients are only able to drink the protein supplement a little at a time throughout the day, while others can drink more [use a children sippe cup]. You should only be concerned that you drink enough.

Myoplex™ Low Carbohydrate

	Showering: If your abdominal drain has been removed, you may shower, but do not take baths. If your abdominal drain is still in place, do not shower.
	Staples or sutures will be removed during your follow-up office visit.
	Activities: You have no restrictions. You should walk at least one mile per day or do the appropriate leg exercises.
	Medications: Resume your routine medications. All medications should be taken crushed. If you are diabetic or have high blood pressure, check your blood sugar and/or your blood pressure several times a day as your requirements for controlling these conditions may decrease.
	Routine vitamins: You may take your daily chewable vitamins.
	Other medications: Additional medications may be prescribed during your first postoperative visit. Follow your doctor’s directions.
	If you do not have a postoperative office appointment scheduled, call for one as soon as possible.