Surgical Pain and Recovery
We think the pain of surgery is the thing that frightens us most about Weight Loss Surgery.
We can't quite figure out how bad it will be, so it becomes bigger and more unbearable in our mind. Some people even decide against the surgery just because they are scared of the pain! However, there are many things we can do to make this huge issue more manageable and less frightening.
Understanding the purpose of pain is the first step. Pain exists as a warning. It tells us that there is something wrong with our body that must be
fixed. The slow ache of a toothache tells us we may wait a week or so for that visit to the dentist, while the acute pain of appendicitis tells us we must seek help quickly. Pain on the surface or in the extremities --a boil or broken wrist -- is usually not as life threatening as an injury to the heart, lungs and internal organs, though places that have many nerve endings -- the fingertips, the face -- can give us very acute localized pain!
Pain literally compels us to do something to relieve it; it is part of our survival system that has allowed us to get help for bodily damage so that we may live. Pain causes many of our bodily systems to help us cope with the injury: it raises our blood pressure, increases our heart rate, produces adrenalin, makes our muscles rigid and us unwilling to move about. This prevents further damage to the area and allows our body to marshall it's defenses to help with the hurt: it sends blood to the needed areas / restricts
other blood flow so we do not lose too much blood from the injury, maintains our blood pressure so our system does not collapse, and performs many other
vital functions so that we can have the best chances for survival.
When we have surgery, our body does not know that we have had a planned remedy or a terrible injury; the same tissue damage, blood loss, shock to our
system, release of maintenance chemicals occurs.
Thus, after surgery, we are in the same amount of pain as if we had been injured in the same way we'd
been operated on: an incision is still an opening in our abdominal cavity -- though, hopefully, our surgeons have made very exacting, precise
moves as they work -- so we have minimal tissue damage and blood loss.
Doctors have access to many different kinds of analgesics that they give us so that we do not have to feel much pain.
Careful management of pain is a key to having as comfortable a surgery as possible. Several things have a direct affect upon our pain management:
1) Our individual pain threshold.
2) Whether we have a chronic pain condition already going on -- or other condition -- that surgery could aggravate.
3) The fact that we are morbidly obese; current pain meds used slow the central nervous system (heart and lungs). If we already have a problem with sleep apnea or hypoxia or getting enough oxygen, remember that our obesity already puts a tremendous strain on our heart and lungs and doctors can only use up to a certain amount of pain medications. More would put us in danger of stopping our heart and lungs.
4) Our surgeon's personal views on pain management.
5) Our communication with our doctor before surgery.
6) Our understanding of pain and pain remedies.
7) Whether you are having a laproscopic or open procedure (an open procedure is an operation using the traditional incision, a laproscopic procedure is
one done using thin tubes, and it involves approx. 5-6 inch-long incisions, which obviously reduces pain and recovery time).
Doctors use two methods for controlling our pain: an intravenous pain killer that enters our bloodstream through a needle placed in a vein, and an
epidural, which is a needle placed into the spinal column that delivers pain medication directly to the nervous systems responsible for the perception of
pain -- bypassing the effects on the heart and lungs.
Though the epidural system would seem safer than the IV system, it DOES carry a small risk of spinal column problems, so some doctors do not choose to
offer it as a first choice for pain relief unless there are proven problems with your breathing and oxygen level, which would make it safer than IV narcotics.
Some people having RNY surgery say the pain is quite bearable; women who have had children often say it's comparable to a hysterectomy or C-section. Other people say the pain is more than they expected. A few people say the pain was quite a bit worse than is usual.
There is no way to predict how much pain you'll have before you have the operation. One guide is if you've had previous surgery; an incision in the abdomen feels pretty much the same no matter which surgery you're having.
The worst of it only lasts about 3-4 days; most doctors will keep you in the hospital until your acute pain is well under control, or has stopped (to make
sure nothing has gone wrong, remember: pain is a warning that something is not O.K.). You are given IV or epidural pain relief this entire time and should not be suffering.
An epidural can block pain perception completely, but it does not work in everyone. If it does not work, you will be given IV narcotics for pain relief.
IV narcotics do not block the perception of pain 100% (if they did, you would be unconscious, and that high a dose would affect your heart and breathing).
If you are given IV narcotics, or if your epidural is taken out and you are put on them, you will feel sore and stiff during this time. You will not be moving quickly. The pain will feel very vaguely there, but not really. As the dose wears off, you will be in a little more pain until your next dose.
To ensure good pain control, many hospitals provide a PCA narcotic pump that utilizes a button you can push to deliver medication to you whenever you feel the pain build. Though this does not give you unlimited narcotics many patients prefer this self-administration because it gives them a feeling of control over their pain without having to
track down a nurse and convince them they need more relief.
Along with these narcotic medications, doctors also use non-narcotic anti-inflammatory medications (like
Toradol or Demerol) that can help a lot with the inflammation and discomfort of surgery without affecting your heart and lungs. This works very well for the majority of WLS patients and, between the epidural and/or IV, and non-narcotic meds, the pain
of the operation IS very bearable.
Remember, depending on your pre-operative medical condition you will be receving other medications. You also may receive blood thinning injections in the immediate post-operative period.
When we go home, we are given liquid or tablet-form, narcotic medications. The tablets must be crushed to take, the liquid is easier, though neither is especially tasty.
We take these meds for approximately a week or so, maybe 10 days. If we are having pain beyond this
point that needs narcotic medication, it is unusual and can be a sign that something is not quite right, and our doctors will want us to come into the
office, or undergo some tests to gauge our condition. Our surgeons want to make sure we don't have a post operative infection or other problem.
Some people are concerned about the issue of addiction. They worry taking narcotic medications in the hospital, and now at home, will cause them to become addicted to them. Some people are even reluctant to take their medications when they are home just for this reason, and they often try and delay taking them as long as possible. This is a mistake; pain that builds up takes a much bigger
dose in the end to relieve than beginning pain does.
When you are home, especially the first three days, take your medications about at the interval that is prescribed, but do not wait until your pain is severe. Take your meds when you are just moderately uncomfortable and that will prevent it from building
up to severe levels that require large doses of medications for relief.
Addiction is not a problem when you take narcotic medications for pain control only. Addiction can start to become an issue if you start to take your meds to get that rush of euphoria and good feeling narcotics provide. Narcotics act on the pleasure centers of the brain, and that's why we feel that rush when we
take them. After surgery -- especially WLS -- we have no energy and do not feel particularly good. We can't do our regular activities, and we are uncomfortable. If you start taking pain meds to counteract these feelings instead of your pain, then addiction is possible.
As long as you use your pain medications ONLY for pain, take them approximately at the prescribed intervals, and start to get your good feelings from your environment, as you always have, addiction is very unlikely to occur. People become addicted when they use the medications for feeling good emotionally instead of their regular activities.
Plan to NOT feel like your usual self after surgery -- and don't expect to. Tell yourself this will pass, and give yourself time to rest and recover. Do not use pain medications to pep yourself up, go to sleep (though you may certainly take or save your regular dose for night to help with that), put yourself in a good mood, cheer yourself up, or to get up
and around before you are ready.
After we get home and have been on narcotics for about a week to 10 days at home, the pain will diminish greatly and will gradually fade into a vague
soreness. It will hurt only when we try and sit up or get out of bed. Maybe we'll feel a little more sore at night after being up all day. At this point, Adult Liquid Tylenol -- which you can buy over-the-counter at the pharmacy -- is usually enough to control any discomfort we have. (And it is only at this point that I am GOING to call it discomfort; before this it is pain and we should not be deluded that it is anything else). If your pain is worse than this, it is very important that you call your doctor and see if you should come in for an office visit.
For the Best Pain Relief:
If you are terribly afraid of pain, have never had an operation before and dread that aspect of it, and want superior pain relief, there are several
things you can do to ensure the highest quality care:
1. Have a long talk with your surgeon. Tell him how apprehensive you are about pain. Do not let him brush off your concerns, or tell you that
'everything will be fine', or that 'most people find it adequate'. Tell him about your reactions to pain in the past; state firmly that you are prepared not to feel 100% pain-free, but that you DO NOT want to suffer. Let him know that you don't want a cookie-cutter approach used for your pain relief.
2. If you've had previous surgery, or have used pain medications for past relief of an injury, TELL your doctor. Specify what drug it was, and how well
it worked. Go back in your memory and recall your reaction to these medications. Note if they made you feel dizzy, nauseous (a common side effect), or if you
had an allergic reaction to them.
3. Have a plan in place -- and ask your doctor specifically -- what he will do if you wake up after surgery and the current method of pain control is not
working, if you are still in the hospital and it is the middle of the night and the pain meds aren't working, and when you're home -- and/or -- it is the middle of the night and your pain meds aren't working. In the hospital, to change pain meds, or up the dose, a doctor has to write the order. Nurses are often reluctant, or just won't call the doctor in the middle of the night to do so. Have a plan in place -- or an actual written order in advance -- so you are not in worse pain than normal until morning. This is especially important if you are in a teaching hospital; doctor's 'rounds' there (where they drag all the student docs with them and visit you) is often the first time your
doc will have a chance to write a new order -- and that may not be until mid-morning.
When you are home and your pain meds aren't working, ask in advance if you should take more of them, take them off schedule, or call his office (the
usual thing to do). Ask if anyone is on call at night and/or the weekends who is willing and able to write a prescription for narcotics if you need them.
Have the number of a 24 hr. pharmacy ready and someone who can drive to get them. If they will not take calls at night or weekends, do not wait until
nighttime to find out if your meds aren't quite working. Take your pain meds before the pain is severe to avoid a painful build up over the course of
the day, and pay attention to how well they work while it is still daytime during the week, so you can call your doctor's office, or go in for a visit, if they are
not working.
For the ride home from the hospital -- especially if it's quite a distance -- make sure you have gotten your last dose of pain meds just before you leave the hospital so they'll work on the ride home. If your trip will take more than three hours, make sure you have some pain meds with you; get your home prescription filled in advance.
Prescription narcotics are controlled substances. Make sure your prescriptionis written out completely (very strong pain meds cannot be called in; you HAVE to take in a written script), all in one color of ink (or they may appear forged), and has all the doctor's license numbers / addresses / phone, etc. on it that it needs to be filled -- ASK the doctor or nurse if the prescription is complete before you leave their office! Prescriptions of controlled substances have a limited number of times they may be refilled or transferred to other pharmacies, so try and get them all filled at the same one (that's why getting them filled in advance, a day or so before you come home is handiest). Often,
liquid narcotics are ordered into a pharmacy in a bulk jug; if your hometown pharmacy is small, these jugs may come in only at certain intervals. Find out if you'll need to call a day or two in advance for a refill -- we don't want you to have to wait for them!
