Pre-Operative Counseling

When discussing your surgery during pre-operative counseling in the office, I will review the details of the surgery with descriptions and diagrams. We will discuss risk factors and individual concerns that need to be addressed. You will understand the healing process, symptoms that you can expect to be relieved with surgery, and your future activity level to optimize the lifelong results of surgery that we aim to achieve. Each surgical plan is individualized to your anatomy, activity levels, and surgical/medical health issues.

Pre-Surgery Bowel Prep Instructions - Day Before Surgery

1. Drink only clear liquids.
2. At noon, take 2 Dulcolax (Bisacodyl) tablets. At 8 pm, take two additional tablets.
3. At 1 pm, mix one capful of Miralax from an 8.3 oz/14 dose bottle into an 8 oz glass of liquid. Mix well before drinking. Repeat process every 15 minutes until bottle of Miralax has been consumed.
4. Do NOT eat or drink anything after midnight on the night before surgery.

Surgery Bowel Prep Document

Pre-Surgery Medication and Prep Instructions

1. Bring all medications with you to the hospital at admission.
2. Take all heart, lung, asthma, and anti-seizure medications as usual on the morning of surgery.
3. Do NOT take blood thinners for five days before surgery.
4. Do NOT take Glucophage pills for 2 days before surgery. (Other hypoglycemic medications are safe).
5. Do NOT take aspirin, Tylenol, or any other anti-inflammatory medicine for 2 weeks before surgery. Do NOT take Goody powders or BC packs for 2 weeks before surgery. If you take these medications for pain and feel that you cannot keep from taking them, please take them as little as possible. These medications make people bleed more freely and make surgery more difficult.
6. Do NOT take any of the following herbs for a full week before surgery: Echinacea, Ephedra, Garlic, Ginkgo, Ginseng, Kava, St. John's Wort, Valerian, and fish oil (Diet Pills must be stopped 2 weeks prior to surgery).
7. Do NOT eat or drink anything after midnight on the night before surgery. And do not drink anything offered by the hospital the day of the surgery
8. Do NOT wear lotion or nail polish on your surgery day.
9. Do tell us if you use a CPAP machine AND bring it with you when you come for surgery
10. DO call if you have any questions.
11. If for any reason you will be late for surgery, or if you must emergently cancel surgery, contact the hopital operator and have her notify Dr. Azar immediately.
12. If surgery needs to be rescheduled for anything non-emergent (whether rescheduling for location, surgery type or date), a $75 rescheduling fee will be collected first.
13. Please be aware that you will be contacted by or billing department regarding the estimated out of pocket cost of your procedure(s). This amount must be paid prior to your surgery, This estimate will not include hospital, etc. feed.
14. Do you have a history of:

• Venous thrombosis
• Heart murmur requiring prophylactic antibiotics
• oints with severe pain or limited range of motion
• Recent (in last 2 months) surgery or hospitalization
• Severe nausea or vomiting after prior surgery

15. Cancelled surgeried within 24 hours prior and no-shows will be charged a $200 fee.
16. Dr. Azar will not know what pain medications you will need postoperatively until after your surgery so she can see what works best for you. Insurance will often require a prior authorization for these medications, however, we have found that it is best to pay cash as that process can take several days. The generic form of these medications are generally less than $20.00. Also, sometimes patients are told they can only receive 7 days of the medication, however, you can pay cash for the full prescription. We discourage the use of Walmart Pharmacy, as they are particularly bad at withholding postoperative pain meds. Small local pharmacies are more service-oriented and likely to get your pain medications filled quickly.

Intra-Operative Policies

During the pre-operative work up on the same day as surgery, patients families will be allowed to stay with them until they go to the immediate pre-operative holding area which occurs approximately one hour before the beginning of the surgery. An IV will be started and pre-operative antibiotics administered in this pre-operative holding area. Throughout the surgical procedure, the patient's family will be informed of the surgery's progress. At the time of surgery, I will see the anatomy in a full relaxation state, and I will sometimes see a need for additional surgery in the pelvic compartment to address a defect that was not visible in the office. I will proceed with this repair if it addresses symptoms that a patient currently has or prevents problems which would likely require further surgery. If I am considering performing a procedure that is not directly related to the surgery goals at hand, I will first discuss that additional surgery with the patient's family and obtain a consent form, intra-operatively, from a family memeber before proceeding. On the other hand, I may choose to forgo a portion of a surgery discussed if I believe that there will be an unreasonable risk for the patient because of unexpected findings such as scar tissue or in the event that a patient becomes unstable medically under anesthesia.

Post-Operative Policies

In the hospital you will receive scheduled pain medicine to allow optimal rest which improves healing time. Antibiotics will be given during surgery, and afterwards as well for some surgeries, depending on the type, location, and sutures used during your surgery. Medicines to prevent nausea will be given before surgery. Some people are aware that they have nausea problems after surgery and for those patients I will give scheduled nausea medicine post-operatively as well. The bladder will lose its ability to feel if it is full, and sometimes its ability to empty, for a short while after surgery. Some bladders wake up in one day and others (less than 1%) may take as long as 4 to 6 weeks.

At home it is important for patients to rest well and take their pain medication as directed. Other instructions that are important to follow are those of bathing and showering. After rectal surgery of any type, sitting in a bath tub is very important as the heat draws our immune system to the area to promote healing, and the cleaning of the cleansing soaks prevents infection of this very bacteria-laden area. Office follow-up instructions will be given and they will allow me to watch for any potential problems. It will be important for you to report vomiting, fever, increasing pain, diarrhea, unusual bleeding, or any other strange symptoms.

Long-Term Post-Operative Activity Consideration

After non-prolapse surgery, activity may return to normal. There is not much research about non-mesh prolapse surgeries but I can speak from 20 years of experience doing these surgeries and following patients over time. In general, I would not recommend any repetitive upper body lifting over 10 pounds or over 20 pounds of lower body pressing. This includes children and grandchildren. For exercises, focus on reps, not weight. For parents and grandparents, if you must carry a heavy little one, try to hold them close to your body to decrease abdominal strain and, if possible, have children climb to your height so that you can avoid lifting them as much as possible. Also avoid high impact exercise. Some of these restrictions are affected by patient physique. Remember that any pressure that you put on your pelvic floor through activity is compounded by your actual weight.

Another problematic issue for some patients is the presence of a chronic cough or times of deep coughing associated with, for example, colds or asthma. I tell these patients to wear a device called Impressa which is a tampon-like device that gives your prolapse repair some additional support during these episodes. There are many patients who want to participate in activities that are relatively vigorous and even in activities that violate these restrictions. I encourage people to speak with me and allow me to follow them as they increase their activity level so that I can watch for early evidence of prolapse so that they can cease the activity if it appears to be problematic. I have been surprised through the years about the many people who engage in vigorous activities and do just fine long term, but I feel obligated to give my general recommendations with a conservative slant.

Risk Note

Risks of surgery that you should be aware of and are encouraged to ask me about include:

• Risk of bleeding during or after surgery with its possible need for transfusion and its inherent risk of transmission of viral infection or reaction.
• Risk of infection or damage to other organs or reaction to or rejection of materials used during surgery.
• Risk of anesthesia or other health condition-related complications such as difficulty with intubation, a cardiac or respiratory event, or perioperative blood clots.
• Risk of reaction or scarring that may render the surgery ineffective for treatment of specific symptoms or cause pain with associated long-term restriction of activities.
• Risk of damages resulting in further hospitalization or surgery or even death.

The above complications are considered major and occur in less than 0.5% of surgeries.

Rescheduling / Late / Cancellation Policies

A patient who cancels surgery less than 24 hours prior to its scheduled time or whose late arrival or failure to arrive for surgery results in cancellation of surgery will be charged a $200 fee.

If for any reason you will be late for surgery, or if you must emergently cancel surgery, contact the hospital operator and have her notify Dr. Azar immediately.

If surgery needs to be rescheduled for anything non-emergent (whether rescheduling for location, surgery type, or date), a $75 rescheduling fee will be collected first.

Billing for Surgery

Please be aware that you will be contacted by our billing department regarding the estimated out of pocket cost of your procedure(s). This amount must be paid prior to your surgery and will not include costs associated with the hospital or other providers' services.

© Published in 2018 by Arden Azar
Property of Renaissance Health and Surgical Associates

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