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Common Operations
 ABDOMINAL AORTIC ANEURYSM REPAIR
WHY DO YOU NEED THE OPERATION?
The reason you need the operation is because the main artery (aorta) in your abdomen has stretched and weakened (aneurysm). Rupture of an aortic aneurysm is usually fatal within minutes or hours unless treated by an emergency operation.
BEFORE YOUR OPERATION
You will usually be admitted into hospital the day before your operation. You may be asked to attend a pre-admission clinic about a week earlier in order to allow time for the tests required to check that you are fit for operation. These tests may include scans of the abdomen or x-rays of the arteries (arteriogram) if these have not already been done. Special tests for your heart, to check that it is working properly, may also be needed.
THE OPERATION
As well as being given a general anaesthetic, you may have a small tube placed in your back (epidural) to help with pain relief following surgery.
Whilst you are asleep, tubes will also be inserted into your bladder to drain your urine, into your stomach (via your nose) to stop you feeling sick, and into a vein in your neck for blood pressure measurements and administration of fluid following surgery.
You will have a cut down or across your abdomen and occasionally it is necessary to make a small cut in one or both groins. The swollen part of the aorta will be replaced by an artificial blood vessel made of plastic. The wounds are closed with dissolvable stitches.
The operation is a major one and approximately 1 in 20 patients die as a result of it.
AFTER THE OPERATION
You will usually be taken to an intensive care (ICU) or high dependency unit (HDU) following your operation so that your progress can be carefully monitored. It is sometimes necessary for you to remain connected to a breathing machine after the operation but you will be taken off this as soon as possible. You may be given oxygen by a mask. Following this sort of surgery, the stomach and bowel stop working for a while and you will be given all the fluids you require in a drip until you can cope with fluids by mouth. A blood transfusion may also be required. The nurses and doctors will try to keep you free of pain by giving pain killers by injection, via a tube in your back, or by a machine which you are able to control yourself by pressing a button. As the days pass, and you improve, the various tubes will be removed and you will be returned to the normal ward until you are fit enough to go home. You will be visited by a physiotherapist before and after your operation who will help you with your walking and your breathing to prevent a chest infection.
GOING HOME
You will feel tired for many weeks after the operation. You should not feel otherwise unwell, and should gradually improve as time goes by. Regular rest is recommended for the first few weeks after surgery, followed by a gradual return to your normal activity. It is usually about three months before you feel as well as you did before the operation.
DRIVING
You will be safe to drive when you are able to perform an emergency stop. This will normally be about 4 weeks after surgery, but if in doubt, check with your own doctor and your insurance company.
BATHING
Once your wound is dry, you may bathe or shower as normal.
WORK
You should be able to return to work within a couple of months following your operation.
LIFTING
You should avoid heavy lifting or straining for several weeks after the operation.
DRUGS
You will usually be sent home on a small dose of aspirin if you were not already taking it. This is to make the blood less sticky. If you are unable to tolerate aspirin, an alternative drug may be prescribed.
SEXUAL ACTIVITY
May be affected due to nerves in the abdomen being cut during the operation or due to changes in the blood flow. You may resume your sex life when you feel comfortable to do so.
COMPLICATIONS
Chest infections can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy.
Slight discomfort and twinges of pain in your wound are normal for several weeks following surgery. Wounds sometimes become infected but this can usually be successfully treated with antibiotics. Also the wound in your groin can fill with a fluid called lymph that may discharge between the stitches but this settles down with time.
As with any major operation, such as this, there is a very small risk of having a medical complication such as a heart attack but the doctors and nurses will try to prevent these complications and deal with them rapidly if they occur.
Occasionally the stomach and bowel are very slow to start working again and this requires patience. Fluids will be provided in a drip until you get back to normal.
WHAT CAN I DO TO HELP MYSELF?
If you were previously a smoker, you must make a determined effort to stop completely. Continued smoking will cause further damage to your arteries and your graft is more likely to stop working. General health measures such as reducing weight, a low fat diet and regular exercise are also important.
ANGIOPLASTY
BEFORE THE PROCEDURE
You will normally be admitted to the ward for a few hours beforehand to check out your general health. If you take regular medications, please have your usual morning dose. If you are a diabetic on insulin, please have your normal food and insulin dose.
Please say if you have any allergies or bad reactions to drugs or other tests. We also need to know whether you have asthma, hayfever, diabetes, bleeding tendencies or any heart or kidney problems. The procedure will take place in the X-ray department.
WHAT IS ANGIOPLASTY?
An angioplasty is a procedure where a small balloon is passed into your artery on the end of a tube (catheter) and is inflated to treat a narrowed or blocked artery. This technique means that in many cases, surgery may be avoided but an overnight stay is generally necessary. You will usually be asked to start taking aspirin before you are admitted as this makes the blood less sticky. The usual dose is 75 mg per day.
THE PROCEDURE
A small needle will be put into the back of your hand and you will be given an injection to make you relax. The radiologist will inject a local anaesthetic into the skin at the groin, "freezing" the area. Occasionally this procedure is undertaken from the wrist or behind the knee. The long fine tube (catheter) is then inserted into the artery at the groin and using X-rays to help, the catheter is manipulated into the correct position. You will not feel the catheter being moved around your body. X-ray pictures are taken whilst the dye is injected down the catheter into the blood vessels. Some injections may cause hot flushing for a few seconds or cramp in the limbs and occasionally there may be a feeling of wanting to pass urine.
Angioplasty takes a little longer than simple arteriography and you may feel the doctor changing and pushing catheters in and out of your groin artery. Although this is occasionally a little uncomfortable, it will not hurt. Sometimes it will be necessary to insert a special device called a stent, to keep the artery open. This is just a small metal cage that expands in your artery permanently to keep the area opened out and allow more blood to flow through. Pressure is applied to the groin wound for about 10 minutes at the end of the procedure to minimise any bruising.
AFTERWARDS
You will be taken back to the ward to rest for a few hours. It is important that you lie quietly so that the groin does not bleed again. The nursing staff will check the groin and foot pulses at regular intervals. In some cases, heparin injection (anticoagulation) will be given for 24 hours to prevent the blood clotting at the site of the angioplasty. Sometimes you may require warfarin tablets to thin the blood for a few months. If you are given heparin or warfarin, this may delay your departure by a few days. Generally the procedure is undertaken as a day case or with an overnight stay.
ARE THERE ANY SIDE EFFECTS?
Some degree of bruising is quite common and this normally disappears in a few days. Serious bleeding is very uncommon but if it does occur, an emergency operation may be required to stop the bleeding (less than 1% of cases).
Sometimes (less than 1% of cases) an operation is required to unblock an artery after angioplasty.
Unfortunately, in about 10% of cases, angioplasty is not successful and other treatments will need to be considered. Even where successful angioplasty has been performed, there is a risk that the area in the artery will narrow down again. After one year, about 20% of arteries will have re-narrowed. If this happens, there is a possibility of repeating the angioplasty. Very rarely, if angioplasty does not work, the circulation may actually worsen.
You cannot do anything yourself to relieve the narrowed artery. However, you can improve your general health by taking regular exercise, stopping smoking and reducing the fat in your diet. These actions will help slow down the hardening of the arteries which caused the problem in the first place and avoid the need for further treatment in the future.
CAROTID ENDARTERECTOMY
WHAT IS THE PROBLEM?
Every day in Great Britain, many people have a stroke (CVA) or warning signs of a stroke (mini stroke or TIA). Such patients are at a higher risk of having another, perhaps major, stroke. All patients with an increased risk of stroke are given medical treatment and advice to reduce this risk. This includes treatment of high blood pressure, diabetes, high fat levels, heart disease and stopping smoking. In addition, aspirin is given.
However, in many cases, surgical treatment is also recommended. In these cases, there is a narrowing of the artery in your neck that supplies blood to the brain. This trouble is due to hardening of the arteries (atherosclerosis). It is important to realise that the left side of the brain looks after the right arm and leg and the right side of the brain looks after the left arm and leg. For this reason, the patient often thinks that the "wrong side" is being operated on, when in fact it is the correct side!
A narrowing in the artery of 70% or more, which has already produced symptoms, results in an annual risk of a further stroke of 10% for about three years. This risk can be reduced to about 2% per year by having a carotid endarterectomy
BEFORE THE OPERATION
Before the operation you will be seen by the anaesthetist. You will have a number of pre-operative tests, including blood tests, a cardiogram (heart tracing) and a chest x-ray. You will be asked to eat or drink nothing for 6 hours before the operation. If you feel unable to sleep the night before, please ask the nurse or doctor to give you a sleeping tablet to allow you plenty of rest.
THE OPERATION
The operation is usually carried out under local anaesthetic. A cut is made in the skin of the neck over the carotid artery. The artery is then temporarily clamped off and the diseased lining removed. The artery is then closed. Sometimes an artificial patch is used to close the artery to prevent narrowing or it may simply be stitched up. Dissolvable stitches will be used to close the skin and there may be a drainage tube coming from the wound which will be taken out the next day.
AFTER THE OPERATION
You will find that your arm is connected to one or two plastic tubes to provide you with fluids and to monitor your blood pressure. You will usually be returned to the ward within a few hours. The operation itself is not particularly painful although you may need some painkillers, which will be given to you if required. On the day after surgery, you will be allowed to get out of bed and to eat normally. In many cases, you may be allowed home on the first postoperative day.
ARE THERE ANY RISKS?
Some bruising around the wound is common after the operation. Bruising of the neck may take several weeks to subside. There is likely to be a numb area on the side of the neck that may take several months to settle down. Occasionally this numbness can be permanent. Temporary weakness of the side of the mouth or tongue is possible though it is only very rarely permanent.
There is a small (but definite) risk of developing a stroke during the operation combined with a very small risk of death. In Great Britain, this combined risk is less than 5%.
WHAT ABOUT AFTERWARDS?
You will usually receive an appointment to be seen in the outpatient clinic in about 3 - 6 weeks. An ultrasound scan, similar to the one that was performed before your operation, may also be arranged to check that the carotid artery is working properly.
The operation usually gives good long-term relief. You can help by improving your general health by taking regular exercise, stopping smoking and reducing the amount of fat in your diet. All these things will help reduce the chances of further trouble from heart attacks and arterial disease.
HERNIA REPAIR
A hernia is an abnormal protrusion, sometimes of bowel, through a defect in the muscle of the abdominal wall. The defect or weakness can occur from birth, or may be due to a strain at that part of the abdominal wall (e.g heavy lifting or during pregnancy). Hernias may occur in the groin area (inguinal or femoral hernia), around the umbilical area (umbilical or paraumbilical), at the top of the abdomen (epigastric or ventral) or around sites of previous operations (incisional hernia).
The operation usually takes place on the day of admission. Many patients undergoing hernia repair go home on the same day as the operation (day case procedure).
ON THE DAY OF ADMISSION
You will not be allowed to eat or drink for about 6 hours before the operation (this may vary depending on the time of your operation).
You will be asked to wear a hospital gown and anti-embolism stockings (to help your circulation).
You should remove any make-up, dentures, contact lenses, jewellery, (wedding rings can be taped over), and any other prostheses.
You may be given pre-anaesthetic medication (pre-med), on the ward before the operation. A ward nurse will then accompany you to theatre. The operation will probably take about half an hour, although larger or complicated hernias will take longer. Hernias are repaired by restoring normal anatomy and often by using a piece of fine mesh to strengthen the muscle wall in that area.
FOLLOWING THE OPERATION
You will go to the recovery area and then return to the ward, where you will be helped back to your bed and made comfortable. Your nurse will check your blood pressure and pulse regularly until stable. The wound(s) may feel numb at first, as local anaesthetic is usually injected. As this wears off, the nursing staff will provide painkillers as required.
POTENTIAL COMPLICATIONS
All surgery may be associated with complications. These may relate to the anaesthetic (the anaesthetist will discuss these with you) or the operation itself. Hernia repair can sometimes cause initial bruising and men having hernias in the groin may find this extends to the scrotum. This resolves in time.
Wound infection is usually simply treated with antibiotics prescribed by your General Practitioner but very occasionally needs further surgery to remove the mesh if it becomes infected. Sometimes people undergoing groin hernia repair may have
problems passing urine after the operation, particularly if a repair has been carried out on both sides. This can be relieved by passing a catheter temporarily, but it could indicate an underlying problem and occasionally requires referral to a urologist (waterwork specialist).
You will notice that under the scar there is a hard ridge in the early weeks. This is completely normal and will disappear over the course of two or three months after the operation. It is also quite common to notice an area of numbness below the scar. Again, this will usually resolve over a couple of months.
A small proportion of patients undergoing surgery for groin hernias develop persistent pain at one end of the wound. This can be due to the anchoring stitch which is deliberately placed close to the pubic bone. It can normally be treated by simple anti-inflammatory medication, but occasionally requires injections into the area and very occasionally further surgery.
Finally there is a risk of hernias recurring in the future. In the case of groin hernias this is in the region of 1-2%.
DISCHARGE ADVICE
Wound care/Stitches: You can bath the day following the operation. Stitches are dissolvable.
Activity:
Mobilise gently after the operation. "Putting your feet up" for a prolonged period of time is the wrong advice. Instead, take things gently for 2-3 days and then resume normal activities as you feel able. Any activity which causes undue strain on the abdomen (such as heavy lifting) should be avoided at first and gradually built up over 6 weeks. You will probably need 2 weeks off work, longer if you have a heavy manual job (unless you can arrange to be on light duties).
Driving:
You will probably be fit to drive after 1-2 weeks. Please check with your insurance company and make sure you feel fully alert and can do an emergency stop safely and comfortably before you resume driving.
Medication:
Painkillers can be provided if required, and will be explained to you.
Medical Certificates:
The ward can provide a sick certificate to cover your hospital stay and convalescence.
Diet:
You may need to increase the fibre in your diet, and fluid intake, to avoid straining due to constipation. A mild laxative such as lactulose may be required and is available without prescription.
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