BREAST BIOPSY UNDER LOCAL ANESTHESIA
Reasons for local anesthesia:  There are sometimes reasons why breast biopsies should be done using twilight sleep or general anesthesia. Increasingly, however, both surgeons and patients are coming to the conclusion that local anesthesia is usually safer, less expensive, and associated with fewer side effects, as well as requiring much less inconvenience and paperwork for the patient. Patients who have never had surgery under local anesthesia are understandably anxious about what they will feel and see. At the end of their first procedure under local anesthesia, however, most volunteer, "I am glad that is over, but it was not bad at all, and I am glad we decided on local."  Further, at least 95% of women who have had breast biopsies under both local and general anesthesia say that they would definitely prefer local next time. Despite these advantages, there are a few situations where general anesthesia is preferable, and I will be happy to discuss these with you if you have doubts about local anesthesia in your particular case.

PREOPERATIVE
Skin preparation:  When time permits and you have an opportunity to do so, we would like to have you wash the skin of the breast with an antibacterial preparation, such as Hibiclens, pHisoHex, or Betadine, for several days before surgery. Do so gently, and do not continue if you skin becomes irritated. If you develop an infection anywhere on your body or a severe cough in the seven days prior to surgery, let us know right away, since these can increase the chances of infection in the breast incision.

Diet:  It is very desirable to avoid drinking alcohol for 12 hours before surgery, but it is certainly okay to eat as you normally would, since there is no need to have an empty stomach for surgery under local anesthesia.

Medications: Except for avoiding blood thinners, aspirin and nonsteroidal pain medications, such as Aleve, Advil and Motrin, continue to take your usual medications on your regular schedule, including the day of surgery.  Ask about this if you have any questions.  Ordinarily we do not find tranquilizers to be necessary or helpful prior to surgery for patients who are not already taking them.  However, if you feel that your situation does call for a tranquilizer, please discuss it with us ahead of time.

Driving:   It is perfectly okay for you to drive yourself to Piedmont Hospital for the biopsy, but you should have someone available to drive you home, since you may still be somewhat distracted and not nearly as good a driver as you usually are. It is okay to drive, if absolutely necessary, later in the day, but, as noted later, we strongly encourage patients to be as inactive as possible throughout the rest of the day of surgery.

Clothing:  We suggest that you wear loose, wrinkle-proof clothing with a loose top that buttons or zips rather than having to be pulled over the head.  Bring a non-under wire bra that is medium snug, but not tight. This bra will need to fit over the bandage, and you will be much more comfortable on the way home with good bra support.  We find that patients are much more comfortable wearing a bra 24 hours a day for several days after surgery.

THE SURGICAL PROCEDURE
At or slightly before the indicated arrival time, you should present yourself to the McDonnell Surgical Center registration desk. Allow for traffic congestion in the Collier and Peachtree Road area from 7:00 AM to 6:30 PM.   The entrance to the McDonnell Surgical Center parking area is off Collier Road, one driveway up the hill toward Peachtree Road from the main Collier Road parking deck entrance.  After registration, you will wait for a while in the lobby.

LOCALIZATION PROCEDURES
In some cases I will be doing the biopsy for an abnormality seen on mammogram or sonogram which cannot be felt.  In these instances, after registering in the McDonnell Surgical Center, you will be sent to the Out Patient Diagnostic Center or the Breast Health Center. There the radiologist will inject Xylocaine to anesthetize the area and will use  sonography and/or mammograms to guide placement of a flexible wire (or wires) down to the area in question to direct our surgery. Each wire is taped to your skin and you will then go back to the McDonnell Surgical Center for another short wait.

Eventually you will be escorted back to the "Minor Surgery" area.  You will be given an opportunity to empty your bladder and then asked to disrobe down to the waist and put on a cotton gown.  I will be sure that you are positioned correctly and will mark the planned incision with a special felt-tip skin-marking pen. I will then put on a mask, "scrub" and put on sterile gloves.  The skin of your breast will be sterilized with Betadine and draped with sterile towels. Next I will inject Xylocaine to anesthetize the entire area.  The injection(s) will sting or ache for several minutes.  After this you will feel movement, pressure, pulling and tugging, but little or no pain.

During the procedure, which usually lasts a little over an hour, you will hear an electronic buzzing noise, indicating use of the electrocautery (electric needle) to prevent bruising.  If you feel any sort of discomfort at any time, tell me, and I will immediately put in more Xylocaine. We have plenty of Xylocaine!

The incision will usually be about 2 inches long and through it I will remove the abnormal tissue. This will be sent to the pathology department where it will be thoroughly analyzed over the next several working days.  I will close the breast tissue and the skin with absorbable sutures, none of which are actually on the outside. Instead of outside stitches, I use adherent paper strips called "Steri-Strips" which should remain in place for many weeks.  They are covered with sterile pads and tape.

AFTER YOUR PROCEDURE
DAY OF SURGERY: After sitting up for a few minutes to regain your equilibrium, you can get dressed. After going over the postoperative instructions with the nurse, you can be on your way. We will give you a few bandages and a prescription for an oral pain medication (usually Percocet, Tylenol with codeine or Darvocet)  to take with you. A sample copy of the "standard" instructions is attached.  You will be given instructions similar to these, individualized to your particular situation, when you leave Minor Surgery. You will have mild to moderate discomfort later in the day and the quieter you are for the rest of the day, the better you will feel.  You should not be hesitant to take the prescription pain medication, but be careful to take it only with something else in your stomach.  Taking strong pain medication on an empty stomach can often cause nausea.  You will soon find that 2 regular Tylenols, perhaps with an Advil, will be quite enough to help you be comfortable.

GENERAL CARE OF YOUR INCISION
The instructions you will be given by the nurse will also emphasize that you should not get the incision area wet for 48 hours - either from a shower or sweating - as this could promote infection and will prematurely loosen the Steri-Strips.  We would like for you to change the initial bandage on the day after surgery, removing the outside tape and 4x3 inch gauze bandage only.  This will expose the steri-strips which cover the actual incision.  Leave the steri-strips in place.  Put a gauze pad back over the steri-strips and place just enough tape to hold the gauze pad in place until you put your bra on.

CARE OF THE STERI-STRIPS
Starting the next day (48 hours after the surgery) you can shower and get the steri-strips wet, with soapy water but do not rub any actual soap across the steri-strips, as it will be very difficult to rinse the soap and this can lead to skin irritation.  Be sure to rinse well. When you get out of the shower blot  (do not rub) the steri-strips with a clean dry towel and let them air dry for 5 to 10 minutes or carefully use a hair dryer. After a few days you will probably be able to stop using "official" bandages with tape, and can protect the incision quite well by first putting on your bra and then gently sliding a gauze pad or a few tissues between the incision and your bra. Usually the steri-strips will remain in place for several weeks, protecting the incision in case of unexpected bumps.  Ends of the steri-strips which loosen and lift up can be gently trimmed as you would a hangnail.

ACTIVITY
You should be very quite on the day of surgery and avoid any impact or contact sports for at least 7 days.  Otherwise, you should be able to resume normal activities within 1 or 2 days, including driving, work, school and housework.

HEALING OF THE INCISION
Do not be alarmed when you notice a lot of firmness around the incision or when you develop rather striking bruising at the incision or lower down on your breast several days after surgery.  The bruising will subside in about three weeks, but the firmness will increase for several months.   The scar will get redder and harder for several months.  It will then gradually fade to a white line within a year or so.  At this point the inside scaring will have softened to some extent as well, and you should familiarize yourself with how the area feels - this is your new "normal"

FOLLOW UP VISITS
Postoperative follow-up visits are usually appropriate (unless you live far from Atlanta) between 7 and 14 days after surgery. Be sure to call and make an appointment for this if it is not made at the time my staff schedules your biopsy.

PATHOLOGY REPORT AND QUESTIONS
You should plan to call our office (404 351 5959)  if you have not heard from us about your pathology in three working days or if you have any concerns or questions about anything, at any time, for any reason!


POST-OPERATIVE INSTRUCTIONS FOR BREAST BIOPSY
1. You may shower beginning today; the dressing is waterproof. After 48 hours, the dressing should be removed and the incision left uncovered, if there are steri-strips, they should be left in place for at least 2 weeks, if possible.

2. Please call my office to make an appointment for approximately 10-14 days following surgery for wound check and removal of sutures.

3. Swimming or any kind of complete submersion of the incision in water should be avoided until after your post-op visit. 

4. You will probably be most comfortable wearing a bra, even at night, for several days to minimize movement of the breast.

5. Please call my office 4-5 days after the biopsy for the final pathology report.

6. Please call my office if you have any questions.


DUCTAL LAVAGE
For patients who may be at increased risk for developing breast cancer we are studying a recently described technique for obtaining a sample of breast duct cells for microscopic examination called "ductal lavage". Using this technique we have two goals in mind. 1) There is a small possibility that we may actually find an early breast cancer; however, the chance of this is probably less than 1%.
2) To determine which women who have risk factors for breast cancer are particularly likely to develop breast cancer in the next 5 years. If we can identify these women we can then discuss more intensive surveillance and/or prophylactic measures.

The technique of ductal lavage is new but has been publicized heavily. The technique is not yet completely proven, but the early information is very encouraging and it appears to be quite safe and well tolerated. It is probably not appropriate for most low-to-average risk women, but if you have risk factors for development of breast cancer (strong family history of breast cancer, previous breast cancer yourself, biopsy showing atypia or "lobular carcinoma in-situ" or you know that you have a genetic predisposition to breast cancer due to BrCa 1 or 2 genes) then you may wish to consider it.

While we (surgeons and pathologists) are refining our technique we are in frequent contact with the experts who have pioneered the technique. We, and the FDA believe that this procedure has advanced beyond "Is it worthwhile?" and that it is now ready for introduction into clinical practice. However we do not know yet how reliable it really is, so data from all the cases that we do will be compiled and analyzed. We will discuss with you how that data is kept confidential.

You should be aware that this sort of "predictive" test will most likely not yet be covered by your insurance, so we will make an effort to obtain a pre-certification from your insurance carrier prior to the procedure, though pre-certification is not a guarantee by the insurance carrier to actually pay for the procedure. If you are interested contact the office at 404-351-5959. A nurse will explain the issues regarding insurance reimbursement, options, etc. Please indicate to the receptionist that you are calling to discuss ductal lavage so that your call can be expedited.


HERNIA SURGERY
PLEASE READ AT LEAST 2 TIMES PRIOR TO SURGERY

PRE and POST OPERATIVE INSTRUCTIONS
IN THE DAYS BEFORE SURGERY:
1. Stop aspirin and aspirin type products such as Bufferin, Advil and most anti-arthritis medication at least seven (and preferably fourteen) days before surgery. Tylenol is OK.

2. Gently wash the area of proposed surgery with HIBICLENS starting 48 hours ahead of time.

3. Notify us if you have a cough or infection anywhere on your body within seven days of surgery.

4. Be sure that you complete all tests and any recommended consultations well in advance of surgery.

5. Eat normally on the night before surgery but take no alcohol after 8PM and nothing  to eat or drink after 12 midnight except prescription medications.

6. Call us if you have any questions about the upcoming surgery.

ON THE DAY OF SURGERY:
1. Have nothing to eat or drink after 12 midnight except for prescription medications  you have been told to take with a sip of water.

2. Leave home with plenty of time to spare as traffic around Piedmont Hospital and in the parking decks can be amazingly congested even before daylight.

3. Follow the instructions you were given about where to report. If you get lost, call a hospital operator by dialing “O” on any hospital telephone.

4. Once you arrive at the proper place, you will be checked in, your paperwork will be reviewed and about an hour before the scheduled start of the surgery, you will be given injection(s) to help you relax. If your situation calls for them, elastic stockings will be placed on your legs to prevent blood clots later.

5. You may have an additional Hibiclens wash and your operative site skin may need to be shaved to minimize pain due to hairiness when the dressing is removed after surgery

6. After all preparations are completed, you will be dressed in a hospital gown and  moved to a stretcher and taken to the preoperative area where an IV will be  started and all of the paperwork will be checked again.  If you are having an “epidural”, it may be placed in the preoperative area. Next you will be transferred onto a narrower table in the operating room. Before surgery begins, and EKG pad will be placed on your back, a blood pressure cuff will be placed on your arm, usually on the side opposite your IV, and an electrocautery grounding pad will be placed on your leg or thigh to allow us to us an electric needle to stop bleeding during surgery, and a device that looks somewhat like a plastic clothespin will be placed on your finger or thumb nail to monitor the oxygen in your blood. Since Piedmont Hospital is a “teaching hospital”, I will have the advantage of a surgical resident assisting me with your surgery. This will help make your surgery safer and quicker and allows me a chance to pass my experience and knowledge along to others. The resident will introduce him/herself to you before surgery and will often have an opportunity to see you again before you leave the hospital.

7. The skin in the area of surgery will be sterilized and anesthesia will be initiated either by injection into the epidural catheter taped to your back or by injection of local anesthetic around the area of the hernia, or both.

8. After checking to be sure that the anesthesia is effective, the incision will be made and the repair carried out, often using mesh or synthetic sutures. After the deep layers of the repair are finished, the skin will be closed with staples or paper tapes  and a bandage will be applied.

9. You will then go to a recovery area until discharge criteria are met, usually several  hours later.  There are six discharge criteria:

 a) You must feel like going home (or to a friend’s or family’s home, etc.)
 b) Your temperature must be under 100 degrees.
 c) You must be emptying your bladder satisfactorily
 d) You must be taking at least liquids by mouth, after which your IV can come out.
 e) Your pain must be adequately controlled with oral pain medications.  You may need injectable pain medications initially, but switch to oral medications as soon as possible

10. The nurses at Piedmont Hospital are among the best anywhere, and they will take very good care of you.  They have extensive experience in caring for patients who have had hernia surgery and they know what to look for ad how to tell when patients are - are not - able to go home safely. They will contact us if they have any reservations about the appropriateness of your going home. If you are not discharged on the day of surgery, we will check on you early the next morning and probably will be able to discharge you then.

11. At least 95% of reasonably healthy patients of all ages undergoing umbilical or  groin hernia surgery will go home on the day of surgery, and fewer than 1% will need to return to the hospital - even briefly - for any reason prior to their scheduled office follow-up.

12. During the several hours following the surgery, you should review the discharge instructions we have given you at least twice. If anything is unclear, check with your nurse right away. If he/she is in doubt also, we will be contacted for  clarification.  A certain amount of insecurity about going home is common, but  there is no need to be uneasy about questions that you haven’t asked or that we haven’t yet answered. When in doubt, ask your nurse; if still in doubt, have the nurse call us. Do not leave until you are sure that you know what you are supposed to do.

13. At the time of discharge, you should be sure to take with you:

 a) Discharge instruction sheet (yellow) from the hospital
 b) Any prescriptions that we have given you.
 c) Gauze pads and tape for dressing changes.
 d) All medications and other personal belongings that you brought with you to the hospital.

14. WHEN IN DOUBT ASK!

POST-OPERATIVE INSTRUCTIONS FOR INGUINAL HERNIA REPAIR

WHEN YOU ARRIVE HOME

ACTIVITY:
1. DRIVING: We discourage driving except in emergencies for several days after surgery. Practice hard braking before actually driving for the first time.

2. SITTING: Until at least seven days after surgery, limit sitting in a chair, car, plan   seat etc. to 30 minutes, after which walk around for 30 to 45 seconds before resuming sitting

3. STAIRS:  No limitations

4. LIFTING: Limited to 20 pounds for the first weeks, gradually increasing to 40 pounds at 14 days and unrestricted lifting after 30 days.

5. RETURN TO WORK /SCHOOL/HOUSEWORK:  Resume limited duties in about 7 days, full duties (including lifting up to 40 pounds) in about 14 days after surgery.

6. STEP LADDERS AND STOOLS: Avoid these and other awkward places for at least 10 days.

7. WALKING: Gradually increase to at least one mile per day by ten days from surgery unless you have other medical problems preventing this.

8. IMPACT SPORTS (JOGGING/AEROBICS): Start gradually no sooner than two weeks after surgery. Avoid any activity that hurts while you are doing it.

9. SEX: Begin cautiously, no sooner than 7 days after surgery. If it hurts, then stop.

10. LUNGS: Take 10 deep breaths and cough hard three times every hour that you are awake for the first 24 hours after surgery to help prevent pneumonia.


WOUND CARE:
1. SUPPORT: Men will usually be more comfortable after groin surgery wearing jockey shorts to support the testicles, which may be temporarily sore and swollen.

Men: Apply ice of testicles in 15 minutes intervals every hour to reduce swelling

2. DRESSING CHANGES: Change the dressing at about 48 hours after surgery, using only gauze and tape; do NOT use antiseptics or ointments.  After 48 hours a dressing is optional.  If you have paper tapes covering the actual incision itself, leave them on. It is okay to get them wet after 48 hours. You may shower and let the soapy water run over the area; do NOT scrub, pat area dry.

3. BATH/SHOWER: These are okay after 48 hours, but do not get soap under that paper tapes and do not scrub area.

4. WOUND SYMPTOMS:  Notify us if there is increasing soreness, swelling, drainage or redness of the wound.  Some bruising and mild swelling is normal.


DIET:
1. GENERAL: Eat sensibly, avoiding hot spicy foods for several days, but there are no specific dietary restrictions

2. BULK/ROUGHAGE: Either eat a bowl of bran daily, or take 1-2 teaspoons pf Metamucil or Citracel or similar product daily to encourage at least one bulky stool daily  (see “Laxatives” below)


MEDICATION:
1. PAIN Usual doses of Tylenol, Advil or Aspirin may be enough.  If not, feel free to have the prescription for pain medication you received filled

2. SLEEP  Over-the-counter Benadryl (25mg to 50mg) is usually enough

3. LAXATIVES It is okay to use any of the available over-the-counter remedies Such as Milk of Magnesia, Mineral Oil, Senokot, Dulcolax tablets or suppositories or Fleet’s enemas. Do not let over 72 hours go by without having a stool

4. VITAMINS Take a multivitamin (any standard brand recommended by your Pharmacist) and a total of at least 500mg of Vitamin C daily for 30 days.

5. OTHER MEDICATIONS  Unless advised otherwise, resume all medications that you were taking before surgery


MISCELLANEOUS:
Arrange to have someone with you around the clock for the first several days after surgery. The purpose is to have someone to handle the household chores, run errands, prepare meals, answer the phone and door, etc.  DO NOT OVER LOOK THIS

You will be much weaker, more forgetful, and less “peppy” than you expect. Do not be alarmed, this is perfectly normal and will gradually improve

If you wear elastic stockings in the hospital. Keep wearing them until you are active and out of bed at least eight hours a days. They may be removed briefly for washing and drying.

Take your oral temperature every day at 4PM and 8PM, write it down and bring the record with you to the office when you return for your post operative visit

IF you sneeze or cough violently, your incision will normally hurt more than it had for several days but this is not a cause for alarm.

Most hernia repair patients have some discomfort for three to five months after surgery

CALL US IF:
The wound is swollen, red or there is increasing drainage which requires dressing changes

Your temperature is 101 degrees within 24 hour of surgery or over 100 degrees after that

If you have sudden or persistent pain anywhere other than the incision.

If you have problems emptying your bladder or burning on urination

LAPAROSCOPIC CHOLECYSTECTOMY

PLEASE READ AT LEAST 2 TIMES PRIOR TO SURGERY

PRE OPERATIVE INSTRUCTIONS- PRELIMINARY PREPARATIONS
Once the diagnosis of gallbladder disease has been confirmed, our office will work with you and the hospital to schedule surgery. As part of the preparation you will have a general evaluation (“history and physical”), appropriate laboratory tests and possibly an EKG and/ or chest x-ray. You will need to review and sign a “consent” form which outlines the risks of surgery and authorizes me, the anesthesiologist, the pathologist, and hospital staff to proceed with your surgery and the other necessary tasks involved in caring for you. You will also be asked to visit the Admission Testing Area (ATA) at the hospital for a preliminary nursing evaluation, additional paperwork, and a discussion with an anesthetist.  In the ATA you will be told exactly what time to arrive, where to park and where to report on the day of surgery.

During this period between the diagnosis and your surgery you should refrain from smoking and must carefully avoid all fats in your diet.  Be sure to let us know if you have a severe episode of pain, your skin becomes yellow, your urine becomes dark (like coca-cola), you develop an infection anywhere on your body, or you develop a cough or fever.  To avoid excessive bleeding during surgery it is helpful to avoid aspirin, Bufferin and other products containing aspirin for up to 2 weeks before surgery.  Non-steroidal arthritis drugs such as Advil, Motrin or Nuprin ( also called NSAIDS)  should be avoided during the 3 days prior to surgery.   If you are taking a blood thinner such as Coumadin, be sure we tell you when to stop. If you are diabetic on insulin you will need special instructions from your regular doctor or from us about this; otherwise, we generally ask for patients to continue their regular prescription medications on the usual schedule, including the morning of surgery with a sip of water.

To reduce the chances of infection in your incisions, we ask that you gently wash the skin of your entire abdomen with a liquid antibacterial soap such as Hibiclens for 3 minutes several times a day for 2 days prior to surgery. Pay particular attention to cleaning your navel but do not scrub hard, and if redness or soreness develops stop using the Hibiclens and let us know.

On the night before surgery, have nothing to eat or drink after midnight except the medications you have been told to take in the morning with a sip of water.

THE DAY OF SURGERY
On the day of surgery, allow plenty of time to get to the hospital; traffic around Piedmont Hospital is generally very congested from about 6:30 AM to 7:00 PM. You will be told ahead of time where to park and present yourself on the day of surgery. There will usually be a brief waiting period in a general waiting area before you are called back to the pre-operative preparation area.  We have room to accommodate only 1 friend or relative in the pre-operative preparation area, so any others accompanying you will have to wait in the larger waiting area during your pre-operative preparation.

In the preparation area an IV will be started in an arm vein and the anesthesia team with includes an anesthesiologist and a Certified Registered Nurse Anesthetist (CRNA) or Physician Assistant (PA) will review all the paper work and answer any additional questions you may have.  Snug elastic stockings will be placed on your legs to help prevent blood clots (phlebitis) and your abdomen may be washed again with Hibiclens.

If your surgery is not the first case of the day the exact start time will depend on the surgery before yours.  As soon as your operating room is ready you will be transported to it on a narrow rolling stretcher.

• At this point those accompanying you can go to the snack bar or take a brief walk and then go to the indicated postoperative waiting area.  There are 2 waiting areas set aside for friends and relatives, and the nurse in the pre-operative area will provide directions.  They should check in at the waiting area within an hour. When the surgery is over I will call to let them know how the surgery went and about what time they will be able to see you.

At this point in the process you will probably meet another member of our surgical team.  We are fortunate to have excellent surgical residents working with us at Piedmont Hospital and the resident and I will work closely together in the Operating Room and afterward.  Laparoscopic surgery can be done by a single surgeon, but I believe strongly that it is much safer to have 2 surgeons working as a team. We will be working on both sides of the operating table, using high definition video screens and up to date equipment. Here, as in all surgery, 2 sets of eyes and hands are much better than one.  After surgery one of the residents is “on call” in the hospital 24 hours a day to see you for any problems that may arise.

One of the anesthesia team will ask you to breathe oxygen through a soft facemask for several minutes and then an anesthetic will be injected into your IV. This may cause a slight burning or aching, but this is not something to worry about; it is perfectly normal. The next thing you will be aware of is waking up in the Recovery Room  (PACU).

THE OPERATION
Once you are sound asleep, a soft plastic tube will be inserted into your trachea (windpipe) and connected to a mechanical ventilator.  While this is being completed we will prepare the abdominal skin with an antiseptic, inject the local anesthetic Xylocaine and make a ¾ inch incision at the navel.  We then insert a “port”, a hollow metal tube about ½ inch in diameter which has a built in valve which allows us to fill the abdomen with carbon dioxide under moderate pressure. Through this port we insert the laparoscope, which combines a camera and a fiber-optic light in a long thin instrument. We take a careful look around for any other abnormalities and occasionally we may find something which alters the planned surgery or adds something else to it.  Usually, however, nothing else  abnormal is seen and we direct our attention to the gallbladder.   Another ½ inch “port” is placed between the navel and the lower end of the breastbone.  This is the port through which we do most of the actual operation. Next a ¼ inch port is placed beneath the ribs on the right and another is placed lower down on the right side. Through these we place instruments to manipulate the gallbladder and hold the liver out of the way. In about 5% of cases, previous surgery, local inflammation, unusual anatomy , bleeding or other technical problems make it impossible to enter the abdomen safely or unwise to continue with the laparoscopic approach due to danger of injury to the bowel or bile duct. When this happens, the laparoscopic instruments are withdrawn and the abdomen (which is always prepared with this possibility in mind) is opened in the traditional manner. The incision for this is usually placed about an inch beneath the ribs on the  right.  Instruments for this are immediately at hand and there is no delay in converting to the open procedure. 

In most cases, however, we are successful in safely using the laparoscope to find the gallbladder and the (cystic) duct which connects the gallbladder to the main bile duct. We carefully separate the cystic duct from the surrounding structures. If x-rays are needed we will make a tiny hole in the cystic duct and insert a small plastic catheter.  We then slowly inject dye while watching on an advanced fluoroscope. A  permanent record can be made of any abnormalities found.  After the x-ray catheter is removed, several titanium clips are placed on the cystic duct and the duct  is divided with tiny scissors.  The artery to the gallbladder is then separated from the surrounding structures, clips are placed on it, and it is divided. After the duct and artery have been indentified, clipped and divided, the gallbladder is carefully separated from the liver. In the early days of laparoscpic surgery a laser was often used for this, hence the name “laser surgery”.. Lasers are no longer used in gallbladder surgery, and we now use the electrocautery or “electric needle” which is much safer.   After the gallbladder is completely separated from the liver, it is withdrawn through the incision at the navel and the specimen is sent to the laboratory for the pathologist to examine. We will occasionally decide to place a small, soft, plastic drainage catheter into the area from which we have removed the gallbladder, usually because of oozing, bile leakage or infection.  This catheter will be connected to a plastic suction bulb that looks like a small hand grenade and can be clipped to your gown, We will teach you how to care for this at home until it is removed, usually several days later.

The upper abdomen is then rinsed with a sterile saline solution through the laparoscope, and the clips on the stumps of the cystic duct and artery are inspected to be sure that they are secure. Next the muscle layer at the navel is closed with absorbable sutures and the skin at all four incisions is closed. We use a technique that does not require  removal of any sutures later and usually involves the placement of small paper strips (called Steri-Strips) on the skin.  Small gauze dressings are placed on the incisions and we usually cover each of these with a small piece of  adherent plastic that permits you to shower as soon as your IV and drains have been removed.

POST OPERATIVE CONVALESCENCE
When you gradually awaken in the recovery room (PACU), you will become aware of discomfort in the four incisions.   Usually the navel incision is the most uncomfortable and this discomfort may increase during the day as the local anesthetic that we have injected around the incisions wears off. You may also have an aching discomfort in your shoulder due to irritation of the diaphragm by the carbon dioxide used to distend the abdomen.  This discomfort is usually helped by moving around and will disappear as the carbon dioxide is absorbed in 24 to 48 hours. For the first 12 to 18 hours the pain will probably be more than you expect based on stories that you may have heard. By the next morning, however, the pain is generally much less, and you too will probably will tell others “ It really did not hurt that much.”  

The length of your hospital stay can vary anywhere from a few hours to several days, depending on your general health, the findings at surgery, your “vital signs”, how rapidly you take liquids and the amount of pain you are having.

We will order strong pain pills for you in the hospital; preferably these should not be taken on an empty stomach as they can sometimes cause nausea. I will give you a prescription for the same pain pills to take with you. Be sure to get the prescription filled on the way home. We will also provide written discharge instructions which you and your family should study very carefully.  A sample of the instructions is attached, and you will be given a similar sheet – perhaps revised in the light of your particular situation -  before you leave the hospital.  The nurse taking care of you will be happy to answer any questions about these instructions.  It is very important that you understand the instructions and that you adhere to them carefully during your convalescence.  Further, you should master them ahead of time, because the general anesthetic will probably interfere with your ability to remember new things for periods of a week or two weeks. We are depending on you and your family to carry out these instructions faithfully, so if for any reason you can’t, please let us know right away.

HOME CARE
You may shower beginning today - the dressing is waterproof. After 2 days, remove the dressing. At this time you may get the incision wet in the shower. Do not submerge your incision in water for one week from the time of your surgery.

You may walk, and you may walk up and down stairs after surgery. You are encouraged to be as active as possible after surgery.

It is usually helpful to use an ice pack on the region of your surgery for the first 24 hours after surgery.

You will be given a prescription for pain medication and are encouraged to use this medication as directed for the first few days.  This will help minimize your post-operative pain and allow you to remain active.

Please notify my office of excessive redness, drainage, swelling or bruising at the site of your incision.

At the time surgery is scheduled we will make an appointment for you to be seen in the office approximately 10-14 days from the time of your surgery to have your wound checked.

If you have constipation due to the pain medication, do not hesitate to take an over-the-counter laxative for the first week after surgery.  Acceptable agents are dulcolax tablets and Milk of Magnesia. Many other over-the -counter agents are also safe and effective. Please use your own direction

© copyright 2000 William E. Mitchell, Jr, MD, PC all rights reserved

LAPAROSCOPIC NISSEN FUNDIPLICATION
PRELIMINARY PREPARATIONS
Once the diagnosis of GERD has been confirmed, our office will work with you and the hospital to schedule surgery.  As part of the preparation you will have a general evaluation ("history and physical"), appropriate laboratory tests and possibly an EKG and/ or chest x-ray. You will need to review and sign a "consent" form which outlines the risks of surgery and authorizes me, the anesthesiologist, the pathologist, and hospital staff to proceed with your surgery and the other necessary tasks involved in caring for you. You will also be asked to visit the Admission Testing Area (ATA) at the hospital for a preliminary nursing evaluation, additional paperwork, and a discussion with an anesthetist.  In the ATA you will be told exactly what time to arrive, where to park and where to report on the day of surgery.   

During this period between the diagnosis and your surgery you should refrain from smoking. Be sure to let us know if you have a severe episode of pain, significant increase in difficulty swallowing, if you develop an infection anywhere on your body, or you develop a cough or fever. To avoid excessive bleeding during surgery it is helpful to avoid aspirin, Bufferin and other products containing aspirin for up to 2 weeks before surgery.  Non-steroidal arthritis drugs such as Advil, Motrin or Nuprin ( also called NSAIDS) should be avoided during the 3 days prior to surgery.  If you are taking a blood thinner such as Coumadin, be sure we tell you when to stop.  If you are diabetic on insulin you will need special instructions from your regular doctor or from us about this; otherwise, we generally ask for patients to continue their regular prescription medications on the usual schedule, including the morning of surgery with a sip of water.

To reduce the chances of infection in your incisions, we ask that you gently wash the skin of your entire abdomen with a liquid antibacterial soap such as Hibiclens for 3 minutes several times a day for 2 days prior to surgery. Pay particular attention to cleaning your navel but do not scrub hard, and if redness or soreness develops stop using the Hibiclens and let us know.

On the night before surgery, have nothing to eat or drink after midnight except the medications you have been told to take in the morning with a sip of water.

THE DAY OF SURGERY
On the day of surgery, allow plenty of time to get to the hospital; traffic around Piedmont Hospital is generally very congested from about 6:30 AM to 7:00 PM. You will be told ahead of time where to park and present yourself on the day of surgery. There will usually be a brief waiting period in a general waiting area before you are called back to the pre-operative preparation area.  We have room to accommodate only 2 friends or relatives in the pre-operative preparation area, so any others accompanying you will have to wait in the larger waiting area during your pre-operative preparation.

In the preparation area an IV will be started in an arm vein and the anesthesia team with includes an anesthesiologist and a Certified Registered Nurse Anesthetist (CRNA) or Physician Assistant (PA) will review all the paper work and answer any additional questions you may have.  Snug elastic stockings will be placed on your legs to help prevent blood clots (phlebitis) and your abdomen may be washed again with Hibiclens.

If your surgery is not the first case of the day the exact start time will depend on the surgery before yours.  As soon as your operating room is ready you will be transported to it on a narrow rolling stretcher.

At this point those accompanying you can go to the snack bar or take a brief walk and then go to the indicated postoperative waiting area.  There are 2 waiting areas set aside for friends and relatives, and the nurse in the pre-operative area will provide directions.  They should check in at the waiting area within an hour. When the surgery is over I will call to let them know how the surgery went and about what time they will be able to see you.

After you are in the Operating Room, you will be moved over onto the operating table. You will probably be rather drowsy, but you may be aware of several people arranging instruments and getting the equipment ready for the surgery.  The "circulator" nurse is in charge of these preparations and there is also a "scrub" nurse or OR technician who prepares and handles all the sterile instruments. There will be large TV monitors on either side of the operating table and a lot of other equipment at the head of the table that will be used by the anesthetist.   A blood pressure cuff will be placed on the arm opposite your IV and inflatable stockings will be placed on your legs.  During surgery the head of the table will be elevated.  When you are in this head-up, feet down position the stockings on your legs are inflated with air pressure once a minute to pump blood back to your heart.  This also helps prevent phlebitis and will be continued until you reach the Recovery Room which is also called the Post Anesthesia Care Unit (PACU).  Four small, sticky electrocardiogram pads with wires will be attached to your skin and a plastic device similar to a clothespin will be placed gently on your thumbnail to monitor the oxygen level in your blood. Wide straps will be placed across your chest and thighs to keep you securely in place as the operating table is tilted.

At this point in the process you will probably meet another member of our surgical team.  We are fortunate to have excellent surgical residents working with us at Piedmont Hospital and the resident and I will work closely together in the Operating Room and afterward.  Laparoscopic surgery can be done a single surgeon, but I believe strongly that it is much safer to have 2 surgeons working as a team. We will be working on both sides of the operating table, using high definition video screens and up to date equipment. Here, as in all surgery, 2 sets of eyes and hands are much better than one.  After surgery one of the residents is "on call" in the hospital 24 hours a day to see you for any problems that may arise.

One of the anesthesia team will ask you to breathe oxygen through a soft facemask for several minutes and then an anesthetic will be injected into your IV. This may cause a slight burning or aching, but this is not something to worry about; it is perfectly normal. The next thing you will be aware of is waking up in the Recovery Room  (PACU).

POST OPERATIVE CONVALESCENCE
When you gradually awaken in the recovery room (PACU), you may l become aware of discomfort in the five incisions.   This discomfort may increase during the day as the local anesthetic that we have injected around the incisions wears off. You may also have an aching discomfort in your shoulder due to irritation of the diaphragm by the carbon dioxide used to distend the abdomen.   This discomfort is usually helped by moving around and will disappear as the carbon dioxide is absorbed in 24 to 48 hours. For the first 12 to 18 hours the pain will probably be more than you expect based on stories that you may have heard. By the next morning, however, the pain is generally much less, and you too will probably will tell others " It really did not hurt that much."  

The length of your hospital stay can vary anywhere from overnight  to several days, depending on your general health, the findings at surgery, your "vital signs", how rapidly you take liquids and the amount of pain you are having.

We will order strong pain medications for you in the hospital; preferably these should not be taken on an empty stomach as they can sometimes cause nausea.  I will give you a prescription for the same pain pills to take with you. Be sure to get the prescription filled on the way home. We will also provide written discharge instructions which you and your family should study very carefully.  A sample of the instructions is attached, and you will be given a similar sheet - perhaps revised in the light of your particular situation -  before you leave the hospital.  The nurse taking care of you will be happy to answer any questions about these instructions.  It is very important that you understand the instructions and that you adhere to them carefully during your convalescence.  Further, you should master them ahead of time, because the general anesthetic will probably interfere with your ability to remember new things for periods of a week or two weeks. We are depending on you and your family to carry out these instructions faithfully, so if for any reason you can't, please let us know right away.

POST-OPERATIVE INSTRUCTIONS
1. You may shower beginning today - the dressing is waterproof. After 2 days, remove the outer dressing leaving the steri strips (paper tape) inplace. At this time you may get the incision wet in the shower. Do not submerge your incision in water for one week from the time of your surgery.

2. You may walk, and you may walk up and down stairs after surgery.  You are encouraged to be as active as possible after surgery.

3. You will be given a prescription for pain medication and are encouraged to use this medication as directed. This will help minimize your post-operative pain and allow you to remain active.

4. Please notify my office of excessive redness, drainage, swelling or bruising at the site of your incisions.  A fever over 101 which is not reduced by Tylenol, nausea, vomiting, cough or increased pain  (404-351-5959)

5. Please make an appointment to be seen in the office approximately 10-14 days from the time of your surgery to have your wounds checked.

6. Do not hesitate to take an over-the-counter laxative for the first week after surgery. Acceptable agents are dulcolax tablets and Milk of Magnesia. Many other over-the-counter agents are also safe and effective. Please consult your pharmacist

Constipation is common after surgery and also may be worsened by pain medications. Consequently, do not hesitate to take these agents in an effort to prevent a problem with post-operative constipation. 

8. You may experience a feeling of tightness or difficulty swallowing from swelling as a result of surgery.  Do not despair as this is to be excepted. In these cases a liquid diet is recommended for 24 to 36 hours and then return to the recommended soft diet. These symptoms will gradually disappear over a period of 6 to 8 weeks

9. You can except to return to work in 7 to 14 days. Avoid heavy lifting (over 15 pounds), all contact sports and abdominal exercise for 4 weeks.  You may drive once you are no longer taking pain medication.

POST SURGERY DIET
After some esophageal surgery, swelling, bruising or spasms may occur. This may result in increased difficulty swallowing and vomiting which could tear the stitches loose. This diet is used to prevent these problems.

Most foods, when well chewed, should pass through the esophagus; however, patients do not always chew foods adequately.  Slow, thorough chewing is recommended. Fluids may not assist with your ability to swallow and in some cases may make swallowing more difficult because of gulping air when drinking. For this reason you may find it best not to drink while eating.  If drinking with meals makes swallowing difficult wait 15 to 20 minutes after you eat to drink any fluids.  Using a straw will prevent gulping air when drinking.

Moistening your foods with sauce, gravy or other liquids may also be beneficial. You should consume only very soft, small particle foods. Please note that you will feel full more quickly than usual.

Foods Allowed Foods NOT Allowed Milk All milk, yogurt, ice creams Any milk product with nuts or dried fruit Protein and Alternates Ground chicken, turkey, beef, fish and pork that is moist. Whole pieces of meat, dry meat, hard cheeses Breads, Cereals and Starches Bread & rolls soaked in liquid, cereal soaked in milk, moist cooked cereals, pasta, mashed potatoes, macaroni & cheese Dry bread or rolls, cereal containing dried fruit or nuts, pastry, or fried potatoes Vegetables Soft cooked vegetables such as corn, peas, carrots Raw, stir fried or any vegetable with strings Fruits Soft cooked, canned or frozen fruits, fresh bananas, fruit juices Any whole fruit except bananas, fruit peelings and skins, dried fruit Soup Broth & creamed soups with small pieces of meat and soft vegetables Cold soup or soup with pieces of raw fruit or vegetables Desserts Pudding, custard, sherbet, ice cream, sorbet, popsicle, jello Pies, cakes, cookies, anything with nuts or dried fruit Beverages All except those not allowed carbonated beverages Fats All except those not allowed Nuts Miscellaneous Hard candy, gum drops, sugar Candy bars containing dried fruit or nuts

PARATHYROID SURGERY
PRE OPERATIVE INSTRUCTIONS
PRELIMINARY PREPARATIONS
Once the surgery has been decided upon our office will work with you and the hospital to schedule surgery.  As part of the preparation you will have a general evaluation ("history and physical"), and sometimes additional scans, sonograms, consultations, laboratory tests and possibly an EKG and/ or chest x-ray. You will need to review and sign a "consent" form which outlines the risks of surgery and authorizes me, the anesthesiologist, the pathologist, and hospital staff to proceed with your surgery and the other necessary tasks involved in caring for you. You will also be asked to visit the Admission Testing Area (ATA) at the hospital for a preliminary nursing evaluation, additional paperwork, and a discussion with an anesthetist. This usually takes 1 to 1 ½ hours.  In the ATA you will be told exactly what time to arrive, where to park and where to report on the day of surgery.    

During the period between the diagnosis and your surgery you should refrain from smoking. Be sure to let us know if you develop an infection anywhere on your body, or you develop a cough or fever. To avoid excessive bleeding during surgery it is helpful to avoid aspirin, Bufferin and other products containing aspirin for up to 10 days before surgery.  Non-steroidal arthritis drugs such as Advil, Motrin or Nuprin (also called NSAIDS) should be avoided during the 3 days prior to surgery.   If you are taking a blood thinner such as Coumadin, be sure we tell you when to stop.  If you are diabetic on insulin you will need special instructions from your regular doctor or from us about this. It is usually best for patients to continue their regular prescription medications on the usual schedule, including the morning of surgery with a sip of water.  Be sure that you are clear about what medications you are to take and when.

To reduce the chance of infection in your incision, we ask that you very gently wash the skin of your neck with a liquid antibacterial soap such as Hibiclens for 3 minutes several times a day for 2 days prior to surgery. It is important that you do this gently and do not scrub hard; if redness or soreness develops, stop using the Hibiclens and let us know. We will be happy to provide a small container of Hibiclens for your use.

Be sure to remember not to eat or drink anything after midnight of the night before surgery except for the medications that you have been told to take in the morning with a sip of water.


THE DAY OF SURGERY
On the day of surgery, allow plenty of time to get to the hospital; traffic around Piedmont Hospital is generally very congested from about 6:30 AM to 7:00 PM. You will be told ahead of time where to park and present yourself on the day of surgery. There will usually be a brief waiting period in a general waiting area before you are called back to the pre-operative preparation area.  We have room to accommodate only 2 friends or relatives in the pre-operative preparation area, so any others accompanying you will have to wait in the larger waiting area during your pre-operative preparation.

In the preparation area an IV will be started in an arm vein and the anesthesia team (which includes an anesthesiologist and a Certified Registered Nurse Anesthetist (CRNA) or Physician Assistant (PA)) will review all the paper work and answer any additional questions you may have.  Snug elastic stockings will be placed on your legs to help prevent blood clots (phlebitis) and your neck may be washed again with Hibiclens if time permits. One of the anesthesia team will also insert a small plastic catheter into an artery (usually at the wrist) to allow blood specimens to be drawn during the procedure.

If your surgery is not the first case of the day the exact start time will depend on the surgery before yours.  As soon as your operating room is ready you will be transported to it on a narrow rolling stretcher.

At this point those accompanying you can go to the snack bar or take a brief walk and then go to the family waiting area. They should check in at the waiting area within an hour. When the surgery is over I will call to let them know how the surgery went and about what time they will be able to see you when you are transferred from the recovery room to your regular room

After you are in the Operating Room, you will be moved over onto the operating table. You will probably be rather drowsy, but you may be aware of several people arranging instruments and getting the equipment ready for the surgery.  The "circulator" nurse is in charge of these preparations and there is also a "scrub" nurse or OR technician who prepares and handles all the sterile instruments. There will be an EKG monitor at the head of the operating table, along with a lot of other equipment that will be used by the anesthetist.  A blood pressure cuff will be placed on the arm opposite your IV and inflatable stockings will be placed on your legs. These stockings are inflated with air pressure once a minute to pump blood back to your heart. These help prevent phlebitis and will be continued until you reach the Recovery Room (Post Anesthesia Care Unit/PACU).  Four small, sticky electrocardiogram pads with wires will be attached to your skin and a plastic device similar to a clothespin will be placed gently on your thumbnail to monitor the oxygen level in your blood.  A wide strap will be placed across your body to keep you secure if we need to tilt the operating table to one side or the other. 

At this point in the process you will probably meet another member of our surgical team.  We are fortunate to have excellent surgical residents working with us at Piedmont Hospital and the resident and I will work closely together in the Operating Room and afterward.  This surgery can be done a single surgeon, but I believe strongly that it is much safer to have 2 surgeons working as a team. We will be working on both sides of the operating table and here, as in all surgery, 2 sets of eyes and hands are much better than one. After surgery one of the residents is "on call" in the hospital 24 hours a day to see you promptly for any problems that may arise.

The anesthesia team will ask you to breathe oxygen through a soft facemask for several minutes and then an anesthetic will be injected into your IV.  This may cause a slight burning or aching, but this is not something to worry about; it is perfectly normal.  The next thing you will be aware of is waking up in the Recovery Room  (PACU).

THE OPERATION
Once you are sound asleep, a soft plastic tube will be inserted into your trachea (windpipe) and connected to a mechanical ventilator. While this is being completed we will prepare the neck skin with an antiseptic and surround it with sterile towels.  When we know in advance where the abnormal parathyroid is located we often remove it through a small incision on one side of the neck. Otherwise, a slightly curving skin incision will be made just above the collarbone centered over the windpipe. The skin is elevated downward to the collarbone and upward to the tip of the Adam's apple. This will cause some numbness of the skin, particularly above the incision for several months. The muscles in the front of the neck run straight up and down and those of each side are very close together in the front of the neck. These muscles are gently separated in the middle and lifted off the thyroid which is shaped like an H. The normal parathyroids are about the size of grains of cooked rice and usually lie behind the thyroid between the windpipe and the carotid artery. They can occasionally be high in the neck or below the breastbone.  They are often very closely attached to the back of the thyroid, and rarely may actually be completely hidden within the thyroid. Almost everyone has at least 4 parathyroids and some people have 5 or even 6 parathyroids.  Most cases  of excess parathyroid hormone are caused by a single abnormal gland, but in approximately ______% of  cases several or even all of the parathyroid glands may be abnormal.  This multiple gland involvement may be part of an inherited syndrome or may occur at random. When multiple glands are abnormal we leave a small amount of parathyroid tissue and remove the rest. We have available in our operating room sophisticated equipment and highly trained technologists for immediate testing of parathyroid hormone blood levels.  When abnormal tissue has been successfully removed, the parathyroid hormone blood level drops dramatically within 5 to 10 minutes, so we can be virtually certain that the operation has been successful. We anticipate successful removal of all abnormal parathyroid tissue in 95% of operations.  Significant complications are uncommon; they include a 1% chance of wound infection and  a rare injury to one of the nerves to the vocal cords resulting in temporary or permanent hoarseness. After surgery for multiple enlarged glands there is an increased chance of persistence of a high calcium level in the blood or a permanent need to take calcium or vitamin D to treat a low calcium level.


The deep layer of the incision is normally closed with absorbable sutures and the skin is closed with paper tapes (steri strips). This technique does not require removal of any skin sutures later. The paper tapes must be left in place for at least one week.  After 48 hours it is OK to remove the outer dressing; replacing it is optional,  depending on what sort of clothes you are wearing, whether the incision bothers you,  whether you are in a dusty area, etc. If the incision gets wet (which is OK after 48 hours) blot it dry and do not turn your head for a few minutes until the paper tapes are dry. The paper tapes will adhere firmly when dry for many days but will loosen prematurely if rubbed when wet.  After several weeks your body may "reject" some of the buried sutures before they dissolve.  These will look like tiny bits of white thread at the edge of the incision.  If you notice this, just cover it with a bandage and let us know.

POST OPERATIVE CARE IN THE HOSPITAL
The postoperative hospital stay can vary anywhere from eight (8) hours to several days, depending on what is found, the magnitude of the surgery, and your overall condition. Most patients are hoarse, have a sore neck and a very sore throat. There may be some nausea after surgery, and medications will be available for this if you ask for them. Most patients are able and anxious to take liquids shortly after surgery and are eating soft food within 24 hours.  The most common reason for delay in discharge beyond 24 hours is a calcium level which has not stabilized at an acceptable level. Some patients have a rapid drop in their calcium levels requiring vigorous calcium replacement, sometimes intravenously. If the calcium level in the blood is not a problem, then almost all patients can be discharged no later than the morning after surgery, so you must make arrangements ahead of time for suitable transportation and for a willing adult to be immediately available in the home around the clock for several days.

At discharge you will be given a prescription for pain medication (usually Percocet, Lortab, Tylenol #3, or Darvocet) but you may find that one extra strength Tylenol and one or two non-steroidal pain medications (NSAIDS) such as Advil or Aleve every four hours will be enough. Virtually all prescription pain medications tend to be quite constipating, and you should take over- the-counter laxatives, suppositories or enemas as needed. Unless otherwise directed, you should resume all pre-operative medications on your usual schedule. One of your physicians will tell you before discharge what we want you to do regarding calcium  and/or Vitamin D at home and we will give you any necessary prescriptions. Be sure that you understand what you are expected to do regarding your medications before you leave the hospital. If any questions come up after you leave the hospital be sure to call.

Once you are home, we would like for you to check your temperature in the evenings at 4 o'clock and 8 o'clock daily for the first three days after discharge.  Let us know if your temperature is over 101 degrees in the first 24 hours after discharge or over 100 degrees at anytime thereafter. If you should develop muscle cramps or severe numbness around the mouth, call and let us know. We would also like for you to call the office at (404) 351 5959 and ask for the triage nurse on the first working day after discharge to let us know how you are doing. At that time you should also schedule a follow up office visit about 7 to 10 days after the surgery (or confirm your appointment if our scheduler has already arranged your post operative visit). You should not drive until you can turn your head easily from side to side. At the follow up visit you can expect to be released to return to normal work/school/home making activities.  We will usually recommend a final post operative visit 2 to 3 months after surgery


THYROIDECTOMY PRE OPERATIVE INSTRUCTIONS
PRELIMINARY PREPARATIONS
Once the surgery has been decided upon our office will work with you and the hospital to schedule surgery.  As part of the preparation you will have a general evaluation ("history and physical"), and sometimes additional scans, sonograms, consultations, laboratory tests and possibly an EKG and/ or chest x-ray. You will need to review and sign a "consent" form which outlines the risks of surgery and authorizes me, the anesthesiologist, the pathologist, and hospital staff to proceed with your surgery and the other necessary tasks involved in caring for you. You will also be asked to visit the Admission Testing Area (ATA) at the hospital for a preliminary nursing evaluation, additional paperwork, and a discussion with an anesthetist. This usually takes 1 to 1 ½ hours.  In the ATA you will be told exactly what time to arrive, where to park and where to report on the day of surgery.    

During the period between the diagnosis and your surgery you should refrain from smoking. Be sure to let us know if you develop an infection anywhere on your body, or you develop a cough or fever. To avoid excessive bleeding during surgery it is helpful to avoid aspirin, Bufferin and other products containing aspirin for up to 10 days before surgery.  Non-steroidal arthritis drugs such as Advil, Motrin or Nuprin (also called NSAIDS) should be avoided during the 3 days prior to surgery.   If you are taking a blood thinner such as Coumadin, be sure we tell you when to stop.  If you are diabetic on insulin you will need special instructions from your regular doctor or from us about this If you have an overactive thyroid we will usually give you prescriptions for iodine and a beta- blocker medication. It is usually best for patients to continue their regular prescription medications on the usual schedule, including the morning of surgery with a sip of water.  Be sure that you are clear about what medications you are to take and when.

To reduce the chance of infection in your incision, we ask that you very gently wash the skin of your neck with a liquid antibacterial soap such as Hibiclens for 3 minutes several times a day for 2 days prior to surgery. It is important that you do this gently and do not scrub hard; if redness or soreness develops, stop using the Hibiclens and let us know. We will be happy to provide a small container of Hibiclens for your use.

Be sure to remember not to eat or drink anything after midnight of the night before surgery except for the medications that you have been told to take in the morning with a sip of water.

THE DAY OF SURGERY
On the day of surgery, allow plenty of time to get to the hospital; traffic around Piedmont Hospital is generally very congested from about 6:30 AM to 7:00 PM. You will be told ahead of time where to park and present yourself on the day of surgery. There will usually be a brief waiting period in a general waiting area before you are called back to the pre-operative preparation area.  We have room to accommodate only 2 friends or relatives in the pre-operative preparation area, so any others accompanying you will have to wait in the larger waiting area during your pre-operative preparation.

In the preparation area an IV will be started in an arm vein and the anesthesia team (which includes an anesthesiologist and a Certified Registered Nurse Anesthetist (CRNA) or Physician Assistant (PA)) will review all the paper work and answer any additional questions you may have.  Snug elastic stockings will be placed on your legs to help prevent blood clots (phlebitis) and your neck may be washed again with Hibiclens if time permits.

If your surgery is not the first case of the day the exact start time will depend on the surgery before yours.  As soon as your operating room is ready you will be transported to it on a narrow rolling stretcher.

 At this point those accompanying you can go to the snack bar or take a brief walk and then go to the family waiting area. They should check in at the waiting area within an hour. When the surgery is over I will call to let them know how the surgery went and about what time they will be able to see you when you are transferred from the recovery room to your regular room

After you are in the Operating Room, you will be moved over onto the operating table. You will probably be rather drowsy, but you may be aware of several people arranging instruments and getting the equipment ready for the surgery.  The "circulator" nurse is in charge of these preparations and there is also a "scrub" nurse or OR technician who prepares and handles all the sterile instruments. There will be an EKG monitor at the head of the operating table, along with a lot of other equipment that will be used by the anesthetist.  A blood pressure cuff will be placed on the arm opposite your IV and inflatable stockings will be placed on your legs. These stockings are inflated with air pressure once a minute to pump blood back to your heart. These help prevent phlebitis and will be continued until you reach the Recovery Room (Post Anesthesia Care Unit/PACU).  Four small, sticky electrocardiogram pads with wires will be attached to your skin and a plastic device similar to a clothespin will be placed gently on your thumbnail to monitor the oxygen level in your blood.  A wide strap will be placed across your body to keep you secure if we need to tilt the operating table to one side or the other. 

At this point in the process you will probably meet another member of our surgical team.  We are fortunate to have excellent surgical residents working with us at Piedmont Hospital and the resident and I will work closely together in the Operating Room and afterward.  This surgery can be done a single surgeon, but I believe strongly that it is much safer to have 2 surgeons working as a team. We will be working on both sides of the operating table and here, as in all surgery, 2 sets of eyes and hands are much better than one. After surgery one of the residents is "on call" in the hospital 24 hours a day to see you promptly for any problems that may arise.

The anesthesia team will ask you to breathe oxygen through a soft facemask for several minutes and then an anesthetic will be injected into your IV.  This may cause a slight burning or aching, but this is not something to worry about; it is perfectly normal.  The next thing you will be aware of is waking up in the Recovery Room  (PACU).

THE OPERATION
Once you are sound asleep, a soft plastic tube will be inserted into your trachea (windpipe) and connected to a mechanical ventilator. While this is being completed we will prepare the neck skin with an antiseptic and surround it with sterile towels.  A slightly curving skin incision will be made just above the collarbone centered over the windpipe. The skin is elevated downward to the collarbone and upward to the tip of the Adam's apple.  This will cause some numbness of the skin, particularly above the incision for several months. The muscles in the front of the neck run straight up and down and those of each side are very close together in the front of the neck.  These muscles are gently separated in the middle and lifted off the thyroid which is shaped like an H.  Removal of one side (lobe) involves identifying the parathyroids, the blood vessels, and the nerves to the vocal cords.  The parathyroids normally lie behind the thyroid between the trachea (windpipe) and the carotid artery. The parathyroid control the calcium level in the blood and each is about the size of a grain of cooked rice.  Sometimes they are tightly attached to the thyroid or even occasionally completely inside the thyroid. Almost everyone has four (4) parathyroids, two (2) on each side, and only one is necessary for normal control of the calcium level in the blood. In about 1% of total thyroidectomies all parathyroids are injured or removed and the patient has to take calcium and vitamin D several times a day, sometimes indefinitely. The laryngeal nerves are also behind the thyroid and run upward along the trachea to enter the larynx (voice box) and control the muscles which control the vocal cords. These nerves are often intimately adherent to the thyroid and can be temporarily or even permanently injured during thyroid surgery.  This can result in significant  hoarseness, weakening and lowering of the pitch of the voice. Permanent injury to the nerves to the vocal cords occurs in about 1% to 3% of thyroidectomies.

When surgery is done for a nodule in one lobe the usual procedure is removal of that lobe and the small crosspiece connecting the two sides called the isthmus. When surgery is done for nodules in both lobes, for a known cancer, or for an overactive gland the entire gland is usually removed.  Depending on the circumstances, some or most of the lymph nodes in the neck may also be removed.

While you are still asleep we will usually send the abnormal tissue to be looked at under the microscope by the pathologist to see whether any malignancy is present and whether any further surgery is indicated. Thyroid tissue is probably the hardest tissue in the body to examine immediately to determine for certain whether a malignancy is present. Some cancers can be firmly diagnosed right away, in which case we usually proceed to complete a thorough cancer operation (which usually involves removing any suspicious lymph nodes and being sure that all visible thyroid tissue has been removed).  In many cases, however the pathologists cannot be absolutely certain initially. If they think that cancer is probably present we usually proceed to remove the other side of the thyroid and any suspicious nodes.  If they believe that no cancer is present nothing further is removed. Unfortunately (and unavoidably) sometimes the pathologists will feel initially that no cancer is present, but cancer will be diagnosed after the tissue has been completely processed several days later.  When this happens we will review the situation with the pathologist, your other physicians, and you. We will outline the options for your particular situation, these usually include doing nothing more, re-operation, radioactive iodine treatment, and/or suppression of your remaining thyroid tissue with medication.

Though not a routine step, we may decide to leave a small suction drain (called a "J.P.") where the thyroid tissue was removed. The deep layer of the incision is normally closed with absorbable sutures and the skin is closed with paper tapes (steri strips). This technique does not require removal of any skin sutures later. The  paper tapes must be left in place for at least one week.  After 48 hours it is OK to remove the outer dressing; replacing it is optional,  depending on what sort of clothes you are wearing, whether the incision bothers you, whether you are in a dusty area, etc.  If the incision gets wet (which is OK after 48 hours) blot it dry and do not turn your head for a few minutes until the paper tapes are dry. The paper tapes will adhere firmly when dry for many days but will loosen prematurely if rubbed when wet.  After several weeks your body may "reject" some of the buried sutures before they dissolve. These will look like tiny bits of white thread at the edge of the incision.  If you notice this, just cover it with a bandage and let us know.

POST OPERATIVE CARE IN THE HOSPITAL
The postoperative hospital stay can vary anywhere from eight (8) hours to several days, depending on what is found, the magnitude of the surgery, and your overall condition. Most patients are hoarse, have a sore neck and a very sore throat. There may be some nausea after surgery, and medications will be available for this if you ask for them. Most patients are able and anxious to take liquids shortly after surgery and are eating soft food within 24 hours.  The most common reason for delay in discharge beyond 24 hours is a calcium level which is not stabilized at an acceptable level. This is a potential problem only if both lobes of the thyroid have been removed. If the calcium level in the blood is not a problem, then almost all patients can be discharged no later than the morning after surgery, and you must make arrangements ahead of time for suitable transportation and for a "willing" adult to be immediately available in the home around the clock for several days.

At discharge you will be given a prescription for pain medication (usually Percocet, Lortab, Tylenol #3, or Darvocet) but you may find that one extra strength Tylenol and one or two non-steroidal pain medications (NSAIDS) such as Advil or Aleve every four hours will be enough. Virtually all prescription pain medications tend to be quite constipating, and you should take over the counter laxatives, suppositories or enemas as needed. Unless otherwise directed, you should resume all pre-operative medications on your usual schedule. One of your physicians will tell you before discharge what we want you to do regarding thyroid medications and/or calcium at home and we will give you any necessary prescriptions. Be sure that you understand what you are expected to do regarding your medications before you leave the hospital. If any questions come up after you leave the hospital be sure to call.

Once you are home, we would like for you to check your temperature in the evenings at 4 o'clock and 8 o'clock daily for the first three days after discharge.  Let us know if your temperature is over 101 degrees in the first 24 hours after discharge or over 100 degrees at anytime thereafter. We would like for you to call the office at (404) 351 5959 and ask for the triage nurse on the first working day after discharge to let us know how you are doing.  At that time you should also schedule a follow up office visit about 7 to 10 days after the surgery (or confirm the appointment if our scheduler has already arranged your post operative visit). You should not drive until you can turn your head easily from side to side. At the follow up visit you can expect to be released to return to normal work/school/home making activities.  We will usually recommend a final post operative visit 2 to 3 months after surgery