Patient Journey

 Before surgery, you will have an appointment with the Preadmission Department where you will meet with an Anesthesiologist and a Nursing team. They will discuss several steps that should be taken prior to your surgery. This may be done over the phone and your current medical history as well as other important information such as your current medications will be collected and reviewed. They will give you directions on how to adjust your medications before surgery, if this is needed.

During this visit, we may also ask you to have some routine tests like an ECG, Chest x ray and blood work to ensure you are fit for surgery.

For patients with complex health conditions, you may also be seen by an Internal Medicine specialist or Endocrinologist.

During this visit you will meet with an anesthesiologist and nursing team. They will discuss several steps that should be taken prior to your surgery. This may be done over the phone and your current medical history as well as other important information such as your current medications will be collected and reviewed.

Questions your anesthesiologist will ask you:

• If you have had any previous operations and anesthetic experiences?
• If you have had any previous operations and anesthetic experiences?
• If any serious complications of anesthesia were experienced by you or your family members (for example, a reaction known as malignant hyperthermia)?
• If you have any allergies or drug sensitivities?
• If you have any chronic medical conditions. If yes, how are they managed and are they currently stable?
• What medications you are taking, including prescription and over the counter medications, as well as any supplements?

Questions you can ask your surgical team:

• What happens during your surgery.
• What kind of help you may need as you recover from surgery.
• When to stop eating or drinking before surgery.
• How to manage your pain and other symptoms.
• Exercises and activities you must do after your surgery and after you leave the hospital.
• How to plan for your recovery after surgery.
• If your surgery might lead to creating a stoma. An enterostomal therapist will be present to discuss what this would entail and how you can manage it in your day-to-day life.

• When to stop eating or drinking before surgery.
• Which of your medications to take or not take prior to surgery. You may need to stop taking some medicines to reduce the risk of severe bleeding (specifically, blood thinners).
• Your options for anesthesia (general anesthetic, regional anesthesia, sedation or combinations of these.)
• The risks of anesthesia in your case given the type of surgery and any other medical conditions you may have (ie. heart, lung, liver, kidneys, thyroid, etc.)
• What options for managing pain after your surgery can be offered (ie. patient controlled analgesia (IV pain pumps), an epidural or a nerve block.

Talk to your family or friends about how long we expect you to stay in hospital so that they are ready to help you when you are discharged home. You may need help with things like meal preparation, grocery shopping, childcare, and transportation to appointments. You may want to stock up the freezer with easy to prepare meals in case you are tired after surgery. For most of our surgeries, we ask that you avoid heavy lifting over 10 lbs (5kg) for the first month after surgery to reduce the risk of a hernia after surgery. Because of this, you may need to ask others for help moving heavy objects.

This week, you may also need to make changes to the medications you are taking before surgery. This will be discussed with you during your Preadmission visit with the Anesthesia team.

• Double check the location of your operation – it could be at either Toronto General Hospital or Toronto Western Hospital.
• Aim to arrive 2-3 hours before the planned start time of your operation.
• You can drink clear fluids up until you arrive in the hospital.

Once you arrive, please go to the Pre-Operative Care Unit (POCU)

You will be checked in by the Ward Clerk and your Nurse double checks your name, date of birth and chart information. They will also make sure that you have a wristband that has your name. If you have allergies or you are at risk of falling while in hospital, we will give you separate allergy or falls risk armband. These will be checked before you go for your surgery.

You change into a hospital gown and you will be placed in either a recliner or on a stretcher (depending on your surgery). The Nurse will place a warming blanket on you to help keep you warm before and during your surgery. This helps lower the chance of infection. You will also be given a disposable hair cap in which you should place all your hair until your surgery is over.

Shortly before your procedure, your Anesthesiologist will meet you to review your medical history and to perform a short pre-operative assessment. This will be similar to the one performed at your pre-admission consult and will act to confirm that the anesthetic plan they created for you is optimized based on your most-up-date health status. An intravenous (IV) may be started in your arm and, you may be given medication to help you relax.

Afterwards, members of your Surgeon and other members of your surgical team will meet you to review your health. At this point, your Surgeon will confirm with you the area on your body where the surgery will happen. They will use a special marker to mark the area. We won’t take you to the operating room until the site is marked. Please don’t mark your body yourself before your surgery.

When it is time, a member of your healthcare team will take you to your OR. When you arrive, members of the surgical team, your Anesthesiologists and OR Nurses will be present to welcome you. Once inside, you will be asked to lay on your back on the OR table and several sensors will be attached. These sensors are used to monitor your vitals (heart rate, blood pressure, oxygen levels, etc.) during your operation.

Before your surgery begins, we will review all of the important information about you out loud. This is called a time out. This makes sure that the operating room team understands and agrees with what they will do. At this point we also confirm the procedure and the site of your surgery. Next, your anesthesia team will give you medications that will put you to sleep through your intravenous (IV) line. They will also give you antibiotics to protect against infection. Some of these medications may create a light burning sensation that will wear off in seconds; you should fall asleep immediately after this point. In many cases, your Anesthetist will choose to have you under general anesthesia, in which case they will insert a breathing tube that will be used to protect your airway and control your breathing; this is called intubation.

Your surgical team will then prepare you for the operation. They will put pads and cushions under your bony areas (elbows, ankles). This prevents any pain and discomfort during your surgery.

If needed, some of your body hair will be removed just before the sites of your incisions are sterilized. Please do not shave or clip your body hair in the area of your surgery at home as this can increase your chance of getting an infection. To sterilize your skin, a reddish purple solution will be applied to your skin and left to dry. You may notice skin discoloration where it was applied after your procedure.

In many cases, your surgical team will insert a foley catheter due to the length of your surgery. This is a catheter that is placed along the full length of your urinary tract in order to drain any urine accumulating in your bladder during your procedure. Best practice requires that the catheter be removed in the first 24 hours after your procedure. An exception is made for some rectal surgeries; the catheter is removed within 48 hours instead. Although not common, once your surgery is done, drains may be left inside your abdomen to help prevent accumulation of fluids during your recovery.

To learn more about the specific surgeries you may undergo, please refer to the Surgical Techniques section.

Once your surgery is over and you are awake, you will be transferred to the recovery room in PACU. There you will be monitored and cared for by a team of Nurses that will either organize your transfer to an inpatient ward or prepare you for your discharge home. Your surgical care team will have organized for you to receive medications for any pain, nausea or vomiting that you might experience afterwards. You will also receive fluids through your IV line until we determine that it is safe for you to start drinking clear fluids again.

Common symptoms you may experience after surgery include:

• Nausea and vomiting from general anesthesia.
• Sore throat (caused by intubation)
• Soreness, pain, and swelling around your incision sites.
• Thirst

Because of some of the medications used by your anesthetist during your surgery, you may experience grogginess during the first day after your procedure. As you recover, a member of our surgical team will contact your family or loved ones to let them know how your surgery went.

What happens next?

If you are alert enough, we will speak to you briefly in the recovery room right after your surgery. However, as it may take some time for anesthetic medications to wear off, we will most likely visit you in the evening following your surgery. By then and if you are being admitted as an inpatient, you will also have been transferred to an inpatient bed and have many of your postoperative symptoms being actively managed.

Minimizing your pain is one of our priorities. We aim to reduce post-surgical pain by using a multi-modal approach to treating it. This generally means that we will use multiple types of pain medications such as Tylenol®, Advil® and opioids to reduce your pain. Although opioids can be more potent analgesics, we try to reduce the doses given to you as they can be associated with side effects such as nausea, vomiting and constipation.

In some cases, we may set you up to control your own pain management using “patient-controlled analgesia,” or IV pumps that let you administer pain medications yourself whenever you feel that your pain level is too high. Your surgeon will discuss whether this is an appropriate option for you.