What to Expect in the Weeks After Skilled Excision Surgery

Just as endometriosis treatment is not one size fits all, recovery will be different for every individual as well. The extent of the disease removed, length of surgery, how your own body heals, and many other factors will come into play. Often extensive excision may take longer to recover from as the surgery may have been longer and more areas on the inside are healing. While the laparoscopic incision on the outside may be small, there may have been extensive work done on the inside that you can’t see. Some people may notice a difference as soon as waking up from surgery. For others it may be weeks before they can tell a difference. Remember to follow your surgeon’s instructions and call that surgeon if you have any questions or concerns!

Surgery is an important step in treating endometriosis but is not the only step. Addressing other pain generators will be important as well. In the meantime, here are some notes from Nancy Petersen on recovery as well as links to other resources for that post-operative time.  

General Things to Know:

• Pain: Pain is common after any surgery and while there are measures to alleviate it, you may not be able to be completely pain free while you are healing. Pain should get better with time. Where pain is felt and the type of pain will differ depending on where work was done. In addition to incisional pain, you may have pain from where lesions were excised. Or if you had additional procedures done, for example if a hysteroscopy (a camera was used to look inside your uterus for any problems such as endometrial polyps), then you may have cramp like type pains. Everyone’s pain tolerance is different and your surgeon will develop a plan for your post-op pain. It is important to know your plan before you go home. While the doctor may prescribe you medications, there may be some over-the-counter medications or other forms of pain control that you will need to know what will be safe for you to use. Remember to ask your provider what is safe for you take. It is important to follow your provider’s instructions. If pain becomes severe and is not relieved by the recommended dose of pain medications, call your provider.

• Gas pain: Most often surgeries are done laparoscopically (using small incisions to insert a camera and instruments). In order to see better, your belly was inflated with a gas. This gas can cause some stomach bloating and cramps as well as shoulder pain (referred pain). While this should go away after a few days, it can be quite uncomfortable. Some individuals find certain positions more comfortable, a soft pillow for support on the abdomen, heat (like a hot water bottle or heating pad on the shoulder- just be careful to avoid burns). 

• Activity: Again, it is important for you to follow your surgeon’s advice about your activity. Every surgery is different and everyone’s body is different. It is normal to feel tired for several days after surgery. A balance of rest and activity is needed for optimal healing. Rest gives your body a chance to heal, but walking and moving around is equally as important to reduce your risks of complications such as blood clots and pneumonia (plus it helps get rid of gas from laparoscopic surgery more quickly!). You should be able to slowly increase your activity. It is good to prepare ahead of time by having your recovery space clean, having groceries available, and arranging for help that you might need. Do not be afraid to ask for help from your loved ones if you need it! Before you leave for home, make sure you have information about incision care, bathing/showering, lifting restrictions, return to work, and returning to sexual activity.
• Nutrition after surgery: This will depend on if your had surgery on your bowels and you should follow your surgeon’s instructions. Some people find that they do not have an appetite for a few days. Pain medications might make you nauseated. Smaller, more frequent easy-to-digest meals will be helpful to have on hand. If you find you are not able to eat or drink, or you start vomiting, then call your surgeon. It’s not unusual to be constipated after surgery- pain medications can worsen constipation. Staying hydrated and eating soluble fiber rich foods can help. Sometimes it takes some time for your gut to balance out. Discuss with your provider any over the counter medications you might need for constipation or diarrhea.
• If you had any additional procedure involving the vagina and/or uterus: If you also had any type of additional procedure involving the uterus, such as a hysteroscopy or hysterectomy, you may notice some spotting, especially after standing up or urinating. However, if the bleeding is heavy or you are at all concerned, then call your provider. Before you go home, ask your surgeon about using tampons (pads are usually okay to use).  Sometimes you may notice some pulling sensations when you urinate, or you may notice problems with urination (such as going more or less frequently than usual). However, call your surgeon if you have any pain or burning with urination, feel the need to urinate frequently or urgently and then urinate only a few drops, develop a temperature above what your discharge instructions say to call about, or have blood in your urine. 
• Follow up Visit: If you have any problems before your follow-up, then do not wait until that visit to call. At discharge from your surgery, you will usually be given a list of symptoms to call about if you have problems. Before your follow-up visit, write down any questions you want to ask at that visit. It is always good to get a copy of your operative note for your records. Don’t forget that other therapies, such as pelvic physical therapy, might be needed to help resolve some symptoms!
• Post Op Shoulder Pain: “Conclusion; heat pads application and early mobilization reduce postoperative shoulder pain and enhance recovery of women undergoing gynecological laparoscopic surgery.” http://www.bu.edu.eg/portal/uploads/Nursing/Maternal%20and%20Newborn%20Health/1833/publications/Aziza%20Ibrahim%20Mohammed%20Hassan_B05121016_6.pdf

Remember, recovery is a marathon, not a sprint! Each individual will have a different experience. Remember to take of yourself and let others help you as needed.

From Nancy:

It Takes Time To Recover From Surgery (you know, involves knives and things)

By Nancy Petersen

“Excision surgery is major surgery, done thru the scope, most times multiple scopes. It involves incisions, tissue removal and pain.  Pain will diminish over a week or so.  Some doctors underestimate the impact on your body, but you need to understand that it takes time to recover and if you ignore that it is at your own peril. You can risk injury, separation of suture lines, infection, hernia, and increased pain. We have said over and over it will be 2 MONTHS MINIMUM before you get a clear idea of how you will do over all, longer if the bowel or other organs are involved rather than simple excision of the sidewalls or pelvic floor.

• The first two periods may be more difficult that normal, sometimes you get lucky and just sail thru them. But expect more difficult periods for the first couple of months.
• Right from the start plan for bowel function, with a discussion with your doctor as to what is ok to take, But stool softeners, dried plums, prune juice, water melon and other fruits. DO NOT let yourself become impacted /constipated because that can easily increase pain. High fiber foods are not recommended in the immediate post op period as the bulk can press on tender operative sites.
• Reduce your pain med intake as quickly as you can as pain meds sedate the bowel, slow it and add to constipation.
• For most excision brings dramatic relief ONCE the post operative healing has taken place. For others it is the first step in eliminating pelvic pain generators. The next step would be (if pain persist beyond 3 months, ) pelvic floor evaluation with a women’s health certified physical therapist, and or bladder evaluation. The thing that excision does not do is treat a uterus that has adenomyosis or other painful conditions, a bladder with IC or a dysfunctional pelvic floor. Those are different conditions and need separate management plans if they are present.
• To expect immediate relief before you have recovered, and or total relief before you have gone thru the first couple months, (longer if bowel, bladder, diaphragm, lung are involved) is unrealistic and inappropriate. Surgery causes a need for healing and pain relief, you still have to take care of yourself diet, fluids, bowel wise.  Fatigue factors may take several months to resolve it your disease was completely removed.
• Find ways to control your anxiety, as stress hormones make everything worse. Rest, relax, learn some relaxation exercises, the internet is full of them, as well as your local book store. Take a leadership role in your recovery.”

Oops I May have Overdone It. Why risk a good outcome

By Nancy Petersen  

“Food for Thought: Recently a number of folks have posted an OOPS, I may have over done it comment post operatively. Without judgement, I have some questions about that. 

* Did you read your discharge instructions, particularly if you had a hysterectomy? If not, why not? Overdoing it after a large surgery can cause suture lines in the vagina to break down, rupture, or fail to heal? They are hard enough to get to heal well without the additional stresses of climbing stairs, lifting things, (anything), and or trying to drive that could involve sudden braking and tearing of sutures. 

* Is the activity you are doing, so important as to risk the outcome of your surgery and the long term impact on recovery? The cost of surgery, travel and trying to ease yourself out of a life time of pain, seems like a big investment to risk doing things you are not yet recovered enough to do. 

* Doctors sometimes minimize the need for recovery time because it is a scope type surgery, but it is still often major surgery and involves recovery from that as well as anesthesia and other medications. You deserve to find relief, but you are part of the solution when it comes to a good outcome from a surgery, take care of yourself, educate yourself, read the resources we have put together for you, and follow your discharge instructions as they are designed for your safety and recovery.

My follow up question would be, are you replacing engaging with and understanding specific instructions from your medical team with anecdotal advice from people on the internet? I know we all love our giant online family – but remember, strangers do not know your case. Your doctor does. Start with that and augment with advice from strangers only after reviewing with your doctor.” 

Links:

• “Laparoscopy: before and after tips”
• “Postop Care – The next 6-12 weeks” 
• “Pain after surgery: what you can expect”
• “Ovaries post-op: suppress them or not?“
• “Post-surgical constipation: an uncomfortable topic – in more ways than one!”
• “Is my endo coming back?”
• “Pain persisting after complete excision surgery: Persistent endometriosis or something else?”
• “My Philosophy on Treating Pelvic Pain Patients”