Hi, my name is Crystal Walker. I am the nurse practitioner here at Pacific Endometriosis and Pelvic Surgery. I am making this video for our pre-op patients. so thank you for watching this before your pre-op appointment. this is kind of going to give you the lowdown of what to expect a day of surgery. And that way, your pre-op equipment time can be used for things that, you know, you still have questions about, things you want clarification on things like that.

so obviously every, pre-op appointment is a little bit different based on what you’re having done. So specifics we’ll talk about more about in your actual appointment. but you will receive, obviously, a pre-op packet from us that has tons of information about, our surgery, your specific surgery, things like that. also included in there are two main things that we want you to be aware of prior to, day of surgery.

Number one, there is a list of medications to stop and when to stop those in that pre-op packet. if you have any questions about that, you can message us prior to your pre-op appointment in the portal, or you can give the nurses a call on the nursing line and, ask them for any clarification that you may need.

the other thing that we need you to be aware of prior to surgery is the bowel prep. So in that, pre-op packet that you receive from us in your email, there is a piece of paper that says bowel prep at the top. You are going to follow those instructions the day before your scheduled surgery. You will start, the bowel prep around noon the day before.

very detailed instructions on how to do that and what to do and when to do it and everything in that packet. it is a combination of Miralax and Gatorade. If you don’t want to use Gatorade for whatever, you don’t reason, you don’t like it, etc.. we typically recommend either a Pedialyte or IV hydration packets as substitutes for that.

If you are having a dual case with Doctor Pi, you are going to follow Doctor Pye’s bowel prep instructions from her office instead of ours. If you are not having a dual case with Doctor Pi, our General surgeon, you will follow our bowel prep. So please keep that in mind. And the goal to our bowel prep is to ideally get you to a point where you are, having liquid bowel movement where it’s very thin.

it doesn’t have to be fully watery, but very thin. Bowel movements. And the purpose of this is to not run clean the way that you would for a colonoscopy. And that’s why, I try to make that clarification. The goal is to get out very large stool from the colon so that it is not obstructing our ability to do your surgery during the your day of surgery.

So that’s our goal here for that bowel prep. Outside of that morning of surgery, you will need to be at Saint Anthony’s Hospital two hours early from whatever time your surgery is scheduled for. So let’s say your schedule, your surgery is scheduled for 730 in the morning. You would need to be at Saint Anthony’s Hospital at 5:30 a.m. when you get to Saint Anthony’s.

If you’ve never been there. The hospital is kind of on a hill, so the main entrance to the building is actually kind of around to the back side of the building. That’s where you will go in at that main entrance. When you do, there is a desk that says admissions and registration directly to the right. That is where you will go and get checked in.

They will have you, show your ID and your insurance card and things like that. go through all the admission process and then once they’re finished, they will get you up into pre-op. In the pre-op area, family can be with you. So family can stay up in pre-op with you while you’re getting prepared. The nurses are going to do all their nursing things right.

They’re going to start your I.V., get your vitals, listen to your heart and lungs, things like that. Doctor Mosbacher will come and see you in this area or Doctor Neuville, if you’re seeing Doctor Neuville and, they will confirm what procedure they’re doing for the day. so excision of endo, preset groaner. Ectomy hysterectomy, whatever they’re planning on doing, they’re going to verbalize and, make sure that we confirm that that’s what we’re doing.

And the purpose of that, of that is to take time out to confirm that we are doing what you want us to do, not doing anything that you don’t want us to do, as well as just gives you an opportunity for any last minute thoughts, questions and concerns, things like that. so that will be in the pre-op area.

After you see one of our providers, you will see whoever is the anesthesia provider for the day, they will come and introduce themselves and explain a little bit about what they do. And then typically, it’s usually not a super long amount of time after you see whoever is the anesthesia provider for the day that you’ll make the transition back into the O.R..

So once you are making that transition, any family that is with you in the pre-op area will go to the main waiting area. As of right now, there are no Covid restrictions, so they are welcome to wait in the lobby in that waiting area the whole time during your surgery. and then you, as the patient will be transferred back into the O.R. at that time, you will be awake as you’re going back, you’re taken back on a rolling, a rolling stretcher bed.

Once you’re in the room, they’ll have you transfer yourself from the stretcher bed to the surgical bed. You’ll be awake for a little while longer while you know, the O.R. team does some Last-Minute things to get the room together. And then, once they’re, you know, settled and ready, they’ll prepare you for that. They’ll put the mask on you, and you’ll slowly go to sleep.

Everyone has to have a urinary catheter during a pelvic surgery, but you will be asleep when that goes in, and you will be asleep when that comes out, unless you’re otherwise told, so no concerns there. Thankfully. and then the first thing that Doctor Mosbacher and Doctor Neuville do is put in what’s called an on Q pain paper.

So there’s another video on our website that will give you a better idea as to what this looks like, as well as how to take it out, which I will talk about. but so you can visualize, on Q pain pump. The point of this is to ideally reduce the need for, prescription pain medicine, obviously, particularly narcotics.

at least in the very acute phase. Postoperatively. So what this looks like is you have a ball that’s about a big external of the body. And within this ball there is a medicine called bupivacaine inside of it. And so from that ball there’s two tiny tubes roughly about the size of a head of a pin that come from the ball through the skin, one under each side of your ribs.

And from that point it feeds internally. All the way down to the bottom of the pelvis. And there’s tiny holes at the end of those tubes so that that medication that bupivacaine can go from that ball through those tubes, out those holes, and then coat the, deep pelvis where we’ve, you know, excised endo and done surgical work, indirect numbing pain relief.

so some things to know about the on cue. It’s completely optional. You are never required to do that. But most of our patients do. the vast majority of our patients do. And, it’s intended to stay in for five days. so if for whatever reason, it was driving you crazy, after surgery, it can definitely be removed before five days.

but the idea is to hopefully leave it in for five days for that, acute post-op pain relief. So some things to know during the five days that you have it. I, there’s nothing that you have to do to it whatsoever than carry it around. It comes with a bag that, is provided with the the ball so that you can carry this around there is no turning it on and off.

There is no pressing buttons to make it work. It’s pressurized. So it’s completely independent. it will most likely leak in the time frame that it is in there. And when I say leak, it leaks where it goes through the skin. That right underneath those ribs, that is a totally common thing for for that on cue pain pump.

That fluid could be clear. It could be bloody, it might be brownish orangish. It could almost be really anything other than something that makes you think infection. so in those cases it would be, you know, white, thick, yellow pus like fluid. Now, that’s not common whatsoever by any means. But if that did happen, you would definitely want to call our office and let us know about that.

if that ever did happen at any point. And then we have patients take this out typically at home on the at the end of day five, post-op. so the other video on the website walks you through exactly how to do that, but it’s essentially a hand over hand motion as you are pulling directly perpendicular away from the body.

and just so you know, those tubes are likely going to be longer than you anticipate them being. The reason for that is, you know, it goes in right underneath the ribs, but you have to envision that it goes basically all the way down to the vagina internally. So don’t be surprised if you’re having to pull longer than you kind of thought that you might.

That’s totally normal. we don’t really have patients complain of it being particularly painful to move, remove the on cue pain pump. not something that we really hear, and feedback, but it might feel a little bit bizarre just because it’s not a normal part of the body. Obviously. and then it’s not uncommon to have a little bit of an increase in your pain after removing the on cue.

And the reason for that is patients just don’t realize quite how much it’s doing for them until it’s not there anymore. So if you need that kind of increase in pain is usually only lasts for a day or so, after removing it. But if you need to increase your oral pain meds during those, a couple days after removing it, that is a totally appropriate thing to do.

And you can absolutely do that. so after she puts in the on cue, we will make at least four. And some patients, we need a fifth, but most patients will have four incisions on their belly. They are all an inch or smaller in size, so roughly about yay big. And, the location of these, you will have one that is right above your belly button, one that is about sick or ten centimeters to the left of that incision, another about ten centimeters to the right of that incision.

And then a fourth one that is about five centimeters above and slightly to the left. if we end up putting in a fifth incision on someone, that’s typically if they have really severe bowel involvement, if they have really big endometrial mas in their ovaries, things like that. So if you are someone that has those things, we might have a fifth incision.

And if that is the case, it is still an inch or smaller in size. And that one will be located, right about over top of your right hip bone. so these are the incisions that the ports go through to allow the robot to hook up. And that is what allows Doctor Mosbacher and Doctor Neuville to do the actual surgeries.

so after we make those, we’ll get the robot hooked up. We will do the actual surgical procedure. if you are someone that is having your hysterectomy just for your knowledge, that includes removal of the uterus, the cervix, and both fallopian tubes. and that all comes through the vagina. So you will have no big incisions on your belly or anything like that.

Once we are finished, we close those incisions with dissolvable sutures that dissolve on their own within 90 days. So there’s no need to come back and have those removed or anything. And then we put skin glue over top of that. so the skin glue takes approximately about two weeks to start falling off by itself. while that is on, it is totally safe for you to get those wet so you can shower and things like that.

Just once you get out of the shower, make sure you dry the glue off really well just so it’s not staying moist. so after we get you closed up and cleaned up, we will get you into what we call recovery Phase one. In this phase, patients are very fresh out of their anesthesia. They’re very, very loopy. so family can’t come back and be with them quite yet just because all of these patients are pretty sedated.

doctor Moss and doctor or and or doctor Neuville will come and see you, and they’ll update you and say, hey, this is what we found. We what we found when we went in and what we did about it. You are not going to remember that conversation because no one does. so after they update you, they will go out into the main lobby and update your family.

they both typically take the surgical photos that they take during your procedure with them to help better explain what they’re kind of describing to your family. So if your family wanted to record that conversation for you as the patient to listen to later, that is totally fine. if they go out into the main lobby and, family is not out there for whatever reason, maybe they stepped away, maybe they left and are planning on coming back.

Whatever. they will call the phone number that you leave for the next person of contact for the day and update them via the cell. If that person were to miss that phone call, for whatever reason, they leave a voicemail. So no matter what, family will be updated. After the doctors go out into the main lobby and update your family, they will come back.

And, Doctor Mosbacher, I know I think Doctor Neuville writes for her prescriptions ahead of time, but Doctor Mosbacher does not. So, we will write for your post-op prescriptions. So Doctor Moss Brooker’s patients will get four written paper prescriptions. They, There is an outpatient pharmacy within Saint Anthony’s Hospital that almost all of our patients have. the nursing staff send their prescriptions down to so that the pharmacy staff can be filling those, and you can actually just take those home with you rather than stopping somewhere to drop those off on your way home.

But if you wanted to do it that way, you absolutely could. That’s fine too. so your first prescription is for a medicine called Zofran ondansetron. That is an anti-nausea medication. so that can strictly be used for any nausea that you may have. postoperatively. and then the other three are kind of a stepwise approach to post-op pain relief.

And what I mean by that is step number one for mild pain. Step number two for moderate pain. Step number three for severe pain. so step number one is a medicine called gabapentin. This is a non narcotic pain reliever. So that is why it is our step number one. Step number two is a medication called tramadol. This medication technically by classification is a narcotic pain reliever.

However it’s usually not as potent or strong for patients as what most people think of when they hear that word. So that’s why it’s our moderate ground, pain reliever. And then step number three for more severe pain is a medicine called Dilaudid. This is a more classic type of narcotic pain reliever, more classic to what you think of when you hear that word.

if and when you should need that medication at any point, it will likely cause drowsiness. so just know that that is a totally normal side effect for that medicine. so each of these can be taken together. And what I mean by that is kind of a stepwise approach. Like I said, if you take, you know, your gabapentin and 30 minutes later you’re not feeling better, you take your tramadol 30 minutes later.

After that, if it’s not improved, to a comparable level, then you can take your Dilaudid. there also like a lot of for example, for the severe pain, if you’re having severe pain, you can absolutely just take the Dilaudid, for that severe pain, rather than going through the steps, obviously, if there’s any patients that are allergic to these medications, we would use something alternative.

In those cases. these medicines are also safe to take with over-the-counter Tylenol. that being said, please do not take more than 3000mg per day. that is the absolute maximum for Tylenol, on a daily basis. And then they are also safe to take with NSAIDs. So an insert is a non-steroidal anti-inflammatory type medication. like an ibuprofen, naproxen, Aleve, Advil.

we actually write for a medicine called spritz for our patients. Unless obviously there’s a contraindication. so spritz is a nasal spray form of a common post post-op in said medication called torrid. All the benefit of it being a nasal spray. Is that a it works quicker and then B it bypasses the belly so that patients don’t get GI upset that a lot of people do with oral NSAIDs.

So those are the benefits of those. and the way this works works is I will put in a prescription at your pre-op appointment. This can only be ordered through a mail order pharmacy out of Chicago. So, the day of your pre-op appointment or a couple days after a pre-op appointment, you will likely get a random phone call from a number that you don’t know out of Illinois.

Please answer that. That is, sprigs calling you. They will verify your prescription and your mailing address, and then they actually just mail this medicine directly to your door. it will come with very detailed instructions on how to use it. So I will not bore you with that. the one thing that I do want everyone to know prior to are actually two things.

Number one, when you spray it, you spray it and then hold the medication in the nostril and let it absorb. Do not inhale and suck up the medicine because this will make this part of your head hurt very bad. It will not feel good. so spray absorb. so that’s number one. Number two, it cannot be used concurrently.

Meaning at the same time, with oral incense, you have to either use one or the other. So if you use a spritz, you spray and you use it and you’re like, I don’t like this. It gave me a headache. Or maybe it made somebody’s eyes water or something, and they would rather use oral ibuprofen. you will wait six hours the way that you would to reduce anyways, which is going to be on the, prescription bottle itself.

so you’d wait for a reader’s time and then just switch yourself to an oral medication, whether that be the ibuprofen, naproxen, a labor Advil, just cannot be taken together because that’s too much. Instead, in a 24 hour period. so that’s kind of our approach to post-op pain relief, along with the on cue pain pump. they, Doctor Mosbacher and Doctor Neuville write for the same medications, for any type of surgery that they are performing.

So just know that just because they write these doesn’t necessarily mean that you will need them. Don’t let it intimidate you. We would just rather patients have something and not end up needing it versus need it, and not have it quickly, readily available to them. so you will spend at least an hour in that first post-op area, sometimes closer to an hour and a half, depending on how patients are coming out of their anesthesia.

after that, you will be moved to what we call post-op two. and once you’re in that second room, family can then come back and be with you in this second room, nurses will probably give you something to drink, something to munch on, see if you can hold these things down. The main thing that they’re going to want you to do is to pee before they let you go home, so your bladder tends to wake up a lot slower than your brain does.

We need to make sure that it wakes back up to do its job and empties independently by itself. so once you do that and you know you’re stable, alert and out of kind of your stupor from being, under anesthesia, fam, nurses will say, okay, she’s, you know, she’s stable. She’s doing good. We’ll get her in a wheelchair and we’ll get her discharged.

so if you live more than two hours ish away, I would really prefer for you to stop. on your drive home and just get out of the car and walk around for a few minutes and move your legs just to prevent yourself from getting sore. help prevent, you know, things like blood clots after surgery, things like that.

Those are not great risks. for most of our patients, obviously. but it’s a good practice to have once you get home, you can anticipate being very, very tired. That is totally normal. Please rest as much as you need to. in your your first few days, you might experience gas pain. So gas is used to inflate the abdominal wall up and out of the way during your surgery so that we can actually get in and be in the areas that we need to be in.

And then once we’re finished, the robot does have a function where it sucks that gas out. Before we close your incisions. However, sometimes a little bit of that sometimes Will gets trapped in there. so the way that you would know that this is happening, patients might have, abdominal bloating distention even. Right shoulder pain is very common with that.

things over-the-counter like gas can be helpful for this. walking is very, very helpful. So frequent ambulation helps getting that gas moving and gets it out of the body quicker. I have also been told that peppermint tea, you know, eating peppermint, things like that have been really helpful for gas pain as well. So that is something you could try if you, have that happen.

If it’s really, really significant, I encourage patients to avoid, carbonated drinks until that gas that, kind of trap gas is gone. So avoid carbonated drinks and, also avoid drinking out of a straw. So, that’s a really small thing to do. But you do swallow more air as you are sipping from a straw. And so it can cause, you know, more trapped air when you’re already battling this trapped gas from surgery.

so and if it is really bad, I encourage patients to avoid those two things until the gas has resolved. for those of you that are having hysterectomy, you might have a little bit of vaginal bleeding. it will likely be very, very minimal in amount. but you can have some light vaginal bleeding typically. that is short lived.

But, you know, some patients don’t have a single drop at all after having a hysterectomy. And somebody could have very light spotting for six weeks post hysterectomy. So both of those things are considered to be within the normal, kind of expectations, the way that you would know that it’s ever too much is if you are saturating a whole pad an hour.

If that is the case, if you are saturating a whole pad an hour with vaginal bleeding after a hysterectomy, you definitely want to call us and let us know that is abnormal. And we will likely, send you to an ER to be evaluated. so those are some things to look for, in kind of the first few days post-op, you will have three homework assignments from us in your first two weeks being post-op.

So number one, we want you to drink lots and lots and lots and lots of water. Stay really, really well hydrated. this is going to help prevent risk of or reduce risk of UTI after having a catheter for a little bit. So that’ll help that. It also helps with, fighting against post-op constipation after anesthesia. and it just helps people heal quicker.

So super important. So number two, every hour that you are awake, meaning if you fell asleep on the couch and you’re napping, please do not wake up out of your nap for this. But if you’re watching TV, if you’re reading a book or whatever, every hour that you’re awake, we want you to get up and walk around the house for a minimum of five minutes.

If it’s more than that, great. but a minimum of five minutes to keep your body moving. It helps control your pain. it’s super important. It also helps with post-op constipation. So you might hear a trend here of post-op constipation. That’s by far the most common side effect that we are, told about after anesthesia. It just kind of is what it is with anesthesia, drinking plenty of water and walking are both going to help with that.

But we also want you to take a stool softener with every single dose of the tramadol and or the Dilaudid. So the step two and three of your prescription, pain medicines. Now if you don’t end up using those much or if or not at all, we want you to take the stool softener at least once in the morning and once at night.

So the most common, thing that we recommend for this is doc, your seat. also under the brand name of coleus, it is a stool softener, meaning it makes the stool softer and easier for you to pass yourself. It is not a laxative, so it’s not like a senna or a miralax or things like that that actually stimulate the body to produce about movement.

However, if you get to day three post-op and you still haven’t had a bowel movement, continue with the stool softener the way that you are taking it. But we also want you to add at least one dose of miralax every day as well, until you do have a more regular bowel movement. now there’s further instructions on what to do as far as like when to do a suppository, when to do, an enema, things like that in the big packet that you get pre-operative, so you can review that as needed.

But most of the time doing the stool softener and, adding the miralax as needed takes care of any issues that we have patients having. so that’s kind of your three homework assignments. for the first two weeks, post up, we will meet virtually with all of our in-town patients, via zoom, around two weeks post-op.

We are going to talk about, you know, how’s your bladder? How’s your bowels? how’s your incisions looking? Any concerns with those? How’s your pain? What are you doing for your pain, etc.? We will also go over your operative report that explains exactly what was done with your individual surgery, as well as your pathology results at that appointment.

It takes us at our office at least a week, sometimes closer to a week and a half, to get pathology back. So that’s why we go over those reports at your two week post-op. And then after we go over those together, we will stick those in the mail and, mail them directly to you so that you have a copy yourself.

and then we meet with each patient at six weeks post-op as well. And typically, for most patients, the six week appointment is trying to make sure that we’re still going uphill and not down right. We’re not having any new setbacks, no new concerns, etc.. so if you are a hysterectomy patient, your six week post-op appointment will be an office.

And the reason for that is that we use a speculum and we look at that vaginal cuff to make sure that that is all healing. Well, there’s no signs of delayed healing, bleeding, infection, things like that. And so that’s why that second appointment for those patients is an office rather than virtual. if you are an out of town patient that has a hysterectomy, please plan on getting either, you know, your general ObGyn or your PCP to, get you on the schedule for a vaginal cuff exam around 6 to 8 weeks post-op.

Ideally, and you just call and let them know, you know, you’re having an out-of-town surgery, and, I need a physical exam around six weeks post-op. Can I get on the schedule for that? And then we actually have patients have those providers send that, office visit note back to us just so we can add that to your chart and show that there is documentation that that has healed well and there’s no concerns there.

and then typically, the only other thing that I talk about in pre-op appointments is the potential for pelvic floor PT. a lot of our patients are already being seen by a pelvic floor physical therapist, but there’s also a lot that have never even been to a, pelvic floor physical therapist. So most of the vast majority of our patients would, would likely benefit from pelvic floor PT after surgery.

and so what I typically do is if a patient doesn’t have any idea of someone near them or someone they’ve used in the past, things like that, I will give them recommendations, based on people that we have referred to in the past. There is also a great website called Pelvic rehab.com. This website allows patients to go, they can put in their individual zip code and it will actually generate kind of a map that will tell you who in that kind of vicinity is, licensed to do pelvic floor PT with you.

and if there’s no one close to you, you can actually, like zoom the map out. If there’s a whole bunch of people and you want to be closer to home, you can zoom the map in. so if for some reason there’s not someone that we have referred to frequently near you, that is a great tool to, see what your options are as well.

And then what most people do is either use the list that we provide them, or the list off of their, pelvic rehab.com site and compare that to their insurance. And that will tell them who is when that within network. And then patients typically make a decision on who to see based on that. so that is kind of the long drawn out story of what to expect in a day of surgery and the first few weeks post-op.

so thank you for listening. And then anything that is not discussed here that is specific to your case, we will review in your actual pre-op appointment. And then obviously any questions that you still have, whether it be on things that I’ve talked about here or, you know, in our actual appointment, I will address all of those then.

So, thank you for your time. I am glad you found us here at, Pacific Endo. And please let us know if you have any questions.