Your Surgery

Pre-Operative Preparation

Once you and the surgeon have decided on a date for surgery, preparation is necessary to achieve the best results.

• VLCD (Very Low Calorie Diet) - most people will need to be on two weeks of a VLCD. The reason for this is to make your liver lighter (reduction of liver volume) as the liver sits on top of the stomach. If your liver is lighter, it is easier to retract upwards and makes your operation safer as it is easier for the surgeon to reach the top of your stomach. Some people will need four weeks if their BMI is above 45 or known fatty liver disease.
• Food on VLCD - you have the option of strict VLCD (three shakes, two half cups of non-starchy vegetables and one tablespoon of olive oil) or the modified program for those on more than two weeks (two shakes then one palm sized portion of lean meat plus non-starchy vegetables)
• Day before surgery: try to stick to fluids as much as possible.
  
• Infections - Treat any tooth, gum, bladder or bowel problems before surgery to reduce the risk of infection
• Smoking - You must be a non-smoker or not smoke for at least 12 weeks prior to surgery. If you relapse, let your surgeon know as soon as possible.
• Medications - discuss with your surgeon and anaesthetist which medications you can take before surgery. Some bleeding medications and some diabetic medications must be ceased 1 week prior.
• Fasting - talk to your anaesthetist; generally you cannot eat for 6 hours before surgery

Packing a hospital bag

• Pack your hospital bag: don't forget to bring
• Charging cables
• Your own pillow
• Comfortable clothes
• not your best pyjamas, there's a good chance you'll stain them
• top and pants - your wounds will be checked frequently so don't wear long dresses!
• Toiletries - toothbrush, toothpaste
• Lip balm if you're prone to cracked lips
• Mouth wash/breath mints if the keto breath bothers you
• Slippers or thongs for walking around the ward

Day of Surgery

Today is the day! Welcome to the hospital.

PRIOR TO YOUR OPERATION

The hospital will advise you what time you need to turn up - generally for morning procedures you need to be at front reception by 6-6:30am, for afternoon procedures you will need to be there by 9:30-10am.

Once you've arrived you'll be in a waiting area until a bed is allocated to you. You'll be asked to change into a patient gown and to wear some tight stockings. These are called TEDS and designed to decrease the risk of clots in your legs. If you have not worn these before you will be fitted for them on admission.

The nursing staff will check you in and ensure you have been appropriately fasted, check your consent form and had the required medication. Sometimes the anaesthetist will give you a medication for anxiety prior to the procedure - if you would like this and haven't been asked, do let the nursing staff know to contact the anaesthetist for you.

The surgeon and the anaesthetist will meet you in the holding bay prior to your operation, to answer any last minute questions you might have.

THE OPERATION

A sleeve gastrectomy will generally take 45 minutes to an hour. A gastric bypass will take anywhere between 1-2 hours on average. Please see each page for further information. 

AFTER THE OPERATION

Once you've woken up in theatre you will be wheeled into the recovery area. You won't remember much of this period as the anaesthetic will still have an effect. The anaesthetist and recovery team will monitor your vital signs as you wake up. Once you're fully awake the recovery nurse will hand over your care to the ward nurse and orderly who will pick you up for transfer.

NIGHT AFTER THE OPERATION

Even though you're on the ward you may not remember a lot of your recovery at this stage. Your friends and relatives are welcome to visit you when you are back on the ward; unless you're in ICU (see below). Check with your hospital for visiting hours and maximum number of visitors. 

You are allow to sip fluid but you will have intravenous fluids running so no need to drink very much.

ICU STAY

Some patients will require an ICU stay for 1 night after the operation. This is generally to ensure you are looked after by 1:1 experienced and specialised nursing staff who watch for breathing difficulties, blood pressure dips or rises, and pain control. This is reserved for those with severe sleep apnoea, BMI above 50 or multiple medical issues.

Day 1 After Surgery

Truth be told, day 1 after surgery is the hardest.

Most people will have "buyer's remorse" on day 1. You may feel bloated, a tightness in the top of your stomach and nauseated.

Here is a list of things you may feel and things to do

• Nausea - some nausea is normal. If you feel you're going to vomit let the nursing staff know; the anaesthetist and surgeon will have prescribed a number of medications to help decrease nausea. Sipping fluids and peppermint tea can help greatly.
• Pain Management - Oral pain relievers will be prescribed to help you manage your pain. Mostly it is a "tightness" rather than pain; walking will help this a lot
• Shoulder tip pain - your surgeon will let out as much of the gas as possible but you may still feel shoulder tip pain. A heat pack can help, as will walking on the ward with your IV pole
• Drinking fluid - you can drink clear fluids, and encouraged to sip one shot glass per hour. Cold water can be hard to drink; warm tea, sweetened juice or broth may be easier
• Breathing - if you've been given an incentive spirometer (a small machine with three balls) use it to make sure you keep taking deep breaths during the day to help clear mucus from your lungs

Day 2 After Surgery

The good news is, day 2 is much easier than day 1. By now you should be feeling more "normal".

The intravenous fluid would have been ceased, you're walking around on the ward and the shoulder tip pain should have lessened.

Today is also the day of discharge from hospital if your recovery has been according to plan. Most hospitals advise a pick-up by 10am on the day of discharge.

Things to consider before going home:

• Pain and Nausea Relief - your team will provide pain relief and anti-nausea medications to take home, this will usually include wafers under the tongue which can be used every four hours
• Bowels - if you have not opened your bowels by day 5 after the operation - take lactulose (20ml 3 times a day) and movicol (2 sachets four times a day) until your bowels have opened. If by day 7 you haven't opened your bowels - use a microlax enema. Each of these are available over the counter at your local pharmacy. Avoid taking a Senna-based medication as these can irritate your gut.

Zero to Two Weeks Post Op

Back at home

The most important thing to consider when your home is to maintain your fluid intake. Sip, sip sip constantly

• Fluids - sip constantly. Your dietitian will have provided guidance regarding which nourishing fluids to drink. You should aim for at least 1-1.5 litres of fluid each day including all clear and nourishing fluids
• Nausea - this should settle within a few days
• Pain - normally patients won't need to take analgesia for more than a few days postoperatively
• Walking - walk as much as you can tolerate (but take your water bottle with you)
• Wounds - your wounds will have a clear skin glue over the top. This might feel a bit itchy by day 7 and by day 10-14 it starts to fall off
• Driving - at least one week after the operation, but make sure you are able to hit the brakes safely before you start driving again.
• Long drives - if you are driving back a long way, make sure you take frequent stops. Get out of the car, walk around every 2 hours or less to stretch your legs. Keep your stockings on.
• Bowels - as before, if you have not opened your bowels by day 5 after the operation - take lactulose (20ml 3 times a day) and movicol (2 sachets four times a day) until your bowels have opened. If by day 7 you haven't opened your bowels - use a microlax enema. Each of these are available over the counter at your local pharmacy. Avoid taking a Senna-based medication as these can irritate your gut.

Long Term

You will have returned to work by two weeks postoperatively (or four weeks if you have to lift heavy things routinely at work). Your life will start to return to normal.

• Diet: your dietitian will give you advice on stages. Generally 0-2 weeks you are on nourishing fluids, 2-4 weeks on puree diet then 4-6 weeks on soft diet. After six weeks you will be on a normal diet in reduced quantity. Keep an eye on your fluid and protein intake.
• Bowels - you might need to keep using the lactulose and movicol in the first few weeks. Once your bowels are established, start a fibre supplement - this is a good way to ensure long term weight maintenance
• Exercise - cardio is fine. Walking, jogging or cycling. Weight lifting or core muscle work (such as pilates) should be avoided until four weeks to ensure wound healing
• Swimming - beach swimming is fine from two weeks. Indoor pools only from four weeks.
• Multivitamins - you will need a multivitamin for life.
• Bloods - you will need follow-up blood tests at 6 months, 12 months then annually (or more frequently if you are diabetic)
• Medications - see your surgeon and your GP. Often we need to cease your blood pressure medication, some diabetic medication and you may not need CPAP anymore