Pre-Op and Post-Op Instructions

• Proof of insurance even though you have been previously approved for surgery.
• Please leave all valuables at home. Please bring only those items that are necessary during your hospital stay.
• If you have an advance healthcare directive, please bring it with you. If you do not have one, this can be taken care of once you are admitted to the hospital.
• The contact information for your referring physician or primary care physician.

• It is strongly encouraged that you leave all valuables at home such as jewelry, money, and credit cards. If need be, your belongings may be kept in a safe at the hospital. An itemized list will be provided. At the time of discharge, you may pick up your belongings.
• You may also leave your valuables with a friend or relative.

• Glasses, hearing aids and dentures will be removed prior to surgery and will be kept with your belongings while you are in surgery.
• Any concerns about the surgery should be discussed with the surgeon beforehand.
• The night before your surgery you may eat a normal meal. Do not eat or drink after midnight the night before surgery.
• You must stop smoking at least 3 months prior to surgery to prevent complications after surgery and to help with your breathing.
• You may shower or bathe as you normally would the night before or the morning of surgery.
• If you should get sick prior to surgery, please notify your doctor.
• Your friends and family will need to wait in the waiting room during the surgery. Please check in with the volunteer. The surgeon will come out to the waiting room to give an update after the surgery. If your family or friends leave, please ask them to leave a phone number as to where they may be reached.

• Informed consent is a form that must be signed by you, the patient and your doctor. This form states that you understand the procedure that you will have, and the benefits and risks associated with the procedure. Before you sign the consent please make sure that your questions are answered and you understand what will be done to you. You have the right to understand your health condition and treatment in terms that you know.
• Informed consent must also include consent for a possible blood transfusion during surgery. If a blood transfusion is required or anticipated you may donate your blood several weeks prior to surgery. These arrangements can be made during the scheduling of your surgery. Blood may also be provided by volunteers. The blood bank screens donated blood to ensure safety.

• Ask your doctor before taking any medication on the day of your surgery. These medications include: blood pressure medications, heart medications, insulin and diabetic medications. If you are diabetic, your surgeon may have special instructions you may need to follow before your surgery.
• Make sure to learn why you take each medication.
• Bring a complete medication list to include all over the counter medications, herbals, supplements and vitamins.
• The medication list should include the doses and times of the medications taken on the day you are admitted.

• Stop certain medications one week prior to your procedure. You must talk to your doctor beforehand. Such medications include:
  • Aspirin
  • Anti-inflammatory drugs i.e.
    • Ibuprofen
    • Aleve
    • Advil
    • Naprosyn
    • Motrin
  • Blood thinning medications such as:
    • Clopidogrel (Plavix)
    • Warfarin(Coumadin)
    • Ticlopidine (Ticlid)

Upon arrival to the hospital, you will be taken to a preoperative area. You will need to change into a hospital gown and your belongings will be placed into a “patient belongings bag.” Your belongings will be locked up for the duration of the surgery or be given to whomever may accompany you. You will meet with the preoperative nurse who will prepare you for surgery. You will also meet with the anesthesiologist and other members of the surgical team who will confirm your medical history and surgery to be performed. Your friends and family members (usually one at a time) may be able to wait with you in the preoperative area until you go to surgery.

The hospital team will consist of various departments which will include: the surgeon, surgical fellows, surgical residents, anesthesiologist, operating room nurses, thoracic surgery nurse practitioners, staff nurses, clinical partners, respiratory therapists, physical therapists, occupational therapists, dietician, social worker, and a case manager.

Upon arrival to the operating room, an operating room nurse will ask your name, your surgeon, and make sure that you understand your surgery. This information will be checked against your identification bracelet and chart.

The operating room may be cool, noisy, and brightly lit. You may ask for a blanket if you are too cold.

General anesthesia will be used. You will be asleep for the duration of the procedure. A tube will be placed in your airway to help you breathe during surgery. You will meet with the anesthesiologist prior to your surgery.

It is important to understand the basic anatomy and physiology of the lungs to better comprehend what will be occurring during surgery and afterwards. Here is a brief description.

The chest or thorax contains several organs. The lungs are located on either side of the heart and are protected by the ribcage.  The airway (trachea) is the tube that connects the mouth to the lungs. The esophagus is the tube that carries food and liquid from the mouth to the stomach. The lungs and chest are covered with a protective layer called pleura. The space between the lungs and the chest cavity is called the pleural space. This space contains a small amount of fluid that allows the lungs to move with ease during breathing.

There are also a number of lymph nodes located in the center of the chest. (The center of the chest is often referred to as the mediastinum.). Lymph nodes are tiny bean shaped glands found in the chest and the rest of the body. They act as filters for foreign particles. Lymph nodes are part of the lymphatic system and contain many type of cells that are important to the immune system. Lymph nodes may become inflamed or enlarged during certain conditions such as an infection or cancer. The lymph nodes located in this area may be removed during surgery to help in a diagnosis.

The function of the lungs is to oxygenate the blood which is done by the action of breathing. Breathing occurs as air is taken in the mouth, the air travels down the airway (pharynx) and through the larynx and into a larger airway called the trachea. The trachea further divides into the left and right mainstem bronchus which leads to the left and right lung. The larger bronchi further branch out into smaller airways called bronchioles. The bronchioles further divide into little airsacs or alveoli within the lungs. The airsacs are surrounded by a network of blood vessels which allow the exchange of oxygen and carbon dioxide into the bloodstream. The right lung has three lobes and the left lung has two lobes. The chest and abdominal cavity are separated by a muscular wall called the diaphragm. The diaphragm aids in breathing as it moves up and down with each breath.

VATS is defined as a minimally invasive surgical approach that uses several small incisions (three) made on the side of the chest (under the arm). During VATS, the surgery is performed through one of three incisions and eliminates the need to spread the ribs. Surgical instruments and a video camera are inserted through these incisions. The surgeon is able to perform surgery by watching on a TV screen. The diseased area is located, examined and removed which allows healthy lung tissue to remain. The amount of lung tissue removed is determined by the areas of destruction seen on the preoperative CT scan.

General anesthesia will be administered and an airway tube will be placed in the windpipe. All patients will meet with the anesthesiologist prior to surgery.

Once surgery is complete, one chest tube will be placed on the surgical side to drain fluid and air. The chest is closed first and then the skin. The sutures are absorbable and do not need to be removed. The sutures where the chest tubes sites are will need to be removed on an outpatient basis about one week after discharge.

The lung sections removed are sent to the pathologist during surgery for analysis. During surgery, a preliminary pathology analysis will be performed to inspect the tissue for cancer cells, infection, or other lung diseases. The final pathology report usually takes 7 to 10 days. The surgeon will review the final pathology report during the follow up appointment one week after discharge.

The surgery may take on average two to three hours. The surgery time is typically less with a VATS procedure than with a thoracotomy.

After surgery you will go to the recovery room for a couple of hours while you are monitored closely by a nurse. The breathing tube is usually removed in the operating room. Vital signs will be monitored closely after surgery. This includes your heart rate which will be monitored by an EKG monitor, taking your temperature, respiratory rate (your breaths), blood pressure (a cuff is placed around your arm and tightens), and oxygen levels (a finger probe is used to measure oxygen levels). Your nurse will also listen to your heart and lungs and assess the surgical sites. Once you have been recovered you will then be moved to the intensive care unit.

• Oxygen will be given by nasal cannula during the first 24 hours after surgery and should be removed the day after surgery as long as oxygen levels are adequate. Oxygen levels will be measured during exercise and at rest using a finger probe or pulse oximeter. The pulse oximeter provides information on how well the lungs are oxygenating and whether a rest during exercise is required, if additional oxygen is needed, or if additional breathing treatments are necessary.
• Incentive spirometer (IS) is a breathing device that helps expand the lungs. The IS involves inhaling through a mouthpiece that is attached to a plastic box containing three balls. The goal of the breathing exercise is to breath deeply to lift all three balls. The exercises must be done at least 10 times every hour while awake. Even though using the IS may cause pain from the surgery, it is important to take deep breaths. This is essential after surgery to prevent postoperative complications such as pneumonia and helps improve lung function.
• Coughing helps expand the lungs and gets rid of sputum which prevents pneumonia. Place a pillow over the incisions and pull it tight while coughing. This helps lessen the pain. You may cough up old blood or blood clots. This is normal as long as it is dark red and is not bright red blood. This will go away in time.
• Breathing treatments will be given as indicated immediately following surgery. The breathing treatments are given by a hand held nebulizer (HHN) with a PEP valve. The HHN delivers medication into a fine mist that must be breathed in deeply. This medication is used to help open up airways and makes it easier to cough up mucus. The PEP valve is attached to the HHN and helps deliver the medications and makes it easier to cough up the mucus. During the breathing treatments, chest physiotherapy will be performed by the respiratory therapist. This is performed by using a soft machine that vibrates the chest wall to help loosen mucus. The breathing treatments with the chest physiotherapy are given every four hours around the clock immediately after surgery.

Pain medication will be given by mouth or through the IV. You will be asked to describe your pain on a scale of 1 to 10 (one being the least amount of pain to 10, being the worst). This pain scale helps determine how well the pain is being managed. Pain medications will be given on an as needed basis. If you are in pain, please tell your nurse. It is important to have adequate pain control as this also helps minimize postoperative complications. If pain is controlled then it will be easier to get out of bed and to complete the breathing exercises. Do not wait until the pain is too severe before you take the pain medication. Please keep in mind that the pain medication reduces pain but does not make it go away completely.

Rarely, pain medication may be given by an epidural or a PCA (patient controlled analgesia). An epidural (a catheter that is placed in the back) may be placed in the operating room at the time of surgery and delivers medication automatically. A PCA allows the patient to deliver a certain amount of pain medication through the IV. Later on during the hospital stay, the epidural or PCA will be removed.

• Chest drainage tube(s) will be in place to drain fluid and air from the chest after surgery and are attached to a drainage box. There will be four chest tubes, two on right side and two on the left side. The chest tube(s) also help the lungs refill with air. They will remain in place until the amount of fluid is minimal and there are no air leaks in the lung. After surgery there can sometimes be an air leak present. This may be from one lung or both lungs. This is common after this surgery and means that the pleura (the covering to the lung) has not healed. As long as an air leak is present the chest tubes will remain in place. If the air leak persists, the chest tubes may be disconnected from the drainage box and attached to a heimlich valve which allows you to move around more easily.
• Heimlich valve is a one way “flutter” valve that allows fluid and air to drain from the chest tubes and is used for a persistent airleak. It is important to never kink the chest tubes and make sure to keep the air vent open. This allows the air to escape from the chest tube. You will be instructed on how to care for the chest tubes and heimlich valve if you are being discharged to home. A home health nurse will visit you to assess the chest tube sites and the heimlich valve.
• Bladder tube (foley catheter) drains urine from the bladder. This may be removed the day after surgery. If an epidural is in place, the catheter will be removed once the epidural has been removed.
• Intravenous (IV) is a catheter placed in a vein. Fluid will be infused through the vein for hydration. The IV may also be used to give medications. The IV fluids will be discontinued when the patient is able to tolerate enough fluid by mouth.

• Diet will start with fluids, and then advanced to a regular or previous diet as tolerated. You must be in a chair for all meals. A loss of appetite is common after surgery. It is important to eat several small meals throughout the day and to supplement with a protein shake. Good nutrition improves strength, promotes wound healing and prevents infection so it is essential to make every effort to eat. A dietician may provide additional information on how to increase calories and protein in your diet.

• SCD’s (sequential compression devices) will be placed on the legs while the patient is in bed. They help circulate blood in the legs to prevent blood clots from forming.
• Activity you will be expected to get out of bed into a chair the day of surgery while in the ICU. The day after surgery you will begin walking…  You will be seen by a physical therapist throughout the hospital stay who will help demonstrate exercises that will help build strength and endurance. You will be asked to rate your level of shortness of breath while exercising using a scale called a Borg scale. The Borg scale is a rating scale of 0 (no shortness of breath) to 10 (very, very short of breath).  The Borg scale is a measure of pulmonary response to exercise. You must walk at least three times a day.  Activity will be increased each day. Walking is very important to prevent complications such as pneumonia, clots in your legs and helps improve lung function. The nurses and clinical partners will also help you get out of bed and assist with walking.
• Range of motions exercises must be performed on the sides that you had surgery (10 times each, 3 times a day).
• Raise your arm over your head with the elbow straight. Bring your arm over your head towards your opposite ear.
• Place your hand behind your neck with the elbow bent and toward your back. Reach toward your shoulder blade.
• Hold your arm straight out in front of you, then cross it over to the other side of your body. Reach for you opposite shoulder.
• Shrug your shoulders up, down and in circles.
• Squeeze your shoulder blades together.
• Walk your hand up a wall until your arm is straight and your chest is against the wall.

• Other medications may be given as needed for nausea.
• Antibiotics may be given to prevent infections. One dose is given prior to surgery and is usually sufficient.
• Stool softeners will be ordered. If you have not had a bowel movement by the second day after surgery, a laxative will be given until you do have one.
• Home medications that you have been taking will be reviewed and resumed if safe to do so.

• Showers may be taken twice a day once all tubes are removed.

PAIN MANAGEMENT, EARLY WALKING, BREATHING EXERCISES AND PROPER NUTRITION WILL ENSURE A QUICKER RECOVERY AND FEWER POSTOPERATIVE COMPLICATIONS AFTER SURGERY. 

• Bleeding – rapid blood loss from the site of surgery can quickly lead to shock. Bleeding complications may occur in the operating room during surgery or after surgery. After surgery, all patients are taken to the recovery room where they are monitored very closely, especially for any signs of bleeding. Treatment of rapid blood loss may include a blood transfusion or a trip back to the operating room to find the source of bleeding. It is important that all blood thinning medications be discontinued at least one week prior to surgery. If blood thinning medications are not discontinued prior to surgery, bleeding may be difficult to stop after surgery. The chest tube(s) in place are one measure to monitor for any bleeding after surgery. Some drainage after surgery is expected. If there are any concerns regarding the amount of drainage after surgery, your surgeon will be notified immediately.
• Infection in the surgical incisions – when bacteria enter the site of surgery, an infection can result. Symptoms may include fever, redness, tenderness, swelling, foul odor and discolored drainage at the surgical sites. Infections delay healing and may spread to other organs or tissue or through the blood stream. Treatment for wound infections may involve antibiotics or drainage of any abscess. Surgical wound infections are prevented by giving an antibiotic prior to surgery, use of sterile surgical technique during surgery, hand washing, wound care after surgery, and proper nutrition.
• Pneumonia/respiratory problems – respiratory problems after surgery are the most common complications. Patients who have respiratory disease or smoke at the time of surgery, a history of prior chemotherapy or radiation are more likely to develop pulmonary complications after surgery. In addition, surgery and anesthesia alter respiratory function by causing underinflation of the lungs which results in atelectasis. The areas in the lungs that are underinflated may lead to pneumonia. Pain from surgery also reduces the effectiveness of coughing and deep breathing which is essential in preventing atelectasis and pneumonia. Symptoms may include worsening shortness of breath, fever, chills, confusion, increased respiratory rate and findings on chest x-ray. If respiratory problems become so severe, the patient may need to be placed on a breathing machine (ventilator) until the problem has resolved. The patient may be placed on antibiotics, require frequent suctioning, and need medications (nebulizers) that help open the airways and loosen any secretions that may be in the airway. Much effort must be taken to prevent and treat postoperative atelectasis and pneumonia including: quitting smoking before surgery,  incentive spirometry, deep breathing and coughing exercises, chest physiotherapy, nebulizer treatments, early walking, and adequate pain management.
• Irregular heart beat/atrial fibrillation – atrial fibrillation is the most common cardiac side effect after thoracic surgery. Atrial fibrillation is an irregular heart rhythm where the atria (two of the four chambers of the heart) are not contracting in a regular manner.  This may cause chest pain, shortness of breath, dizziness, low blood pressure, sweating, a feeling that your heart is racing, EKG changes, and abnormal lab values (elevated cardiac enzyme levels). Risk factors for irregular heart rhythms include patient related (i.e. preexisting heart disease, poor lung function, high blood pressure, and older age), surgery related (type of surgery performed, duration of surgery, types of anesthesia used, and any problems during surgery such as bleeding) or due to prior treatments (previous chemotherapy or radiation). If a patient is considered high risk for an irregular heart rhythm, medications may be started right after surgery to prevent this from occurring. This medication will be continued after discharge from the hospital for approximately one month. If a patient should have an irregular heart rhythm in the hospital, certain medications may be given through the IV or by mouth to control the heart rhythm. At times, a cardiologist (heart specialist) may be asked to see the patient. If the heart rate is severe (too fast and resulting in significant symptoms), the patient may be required to go to the intensive care unit for ongoing monitoring.
• Blood clot – sometimes blood clotting occurs within the deep veins after surgery. Large blood clots can break free and clog an artery to the heart or lungs, leading to heart failure, breathing difficulties or respiratory failure. Signs and symptoms of a blood clot are: pain and swelling in the calf of the leg, fever with chills, difficulty breathing, increased heart rate, and irregular heart rhythms. Diagnosis may be done by obtaining a duplex (ultrasound) of the legs or a CT scan of the chest to determine if a blood clot is present. The best treatment for a blood clot is prevention. This is done by walking frequently after surgery, wearing antiembolic stockings, and SCD’s (sequential compression devices) or leg squeezers. Additionally, during the postoperative period, most patients are started on heparin injections two to three times a day as a measure to prevent blood clots. If a clot occurs, treatment depends of the location and extent of the blood clot but may include drugs or surgery.
• Prolonged air leak – an air leak happens when air from the lung tissue (usually at the suture line) leaks out into the chest cavity. If the volume of air inside the chest becomes too great, the pressure could cause the lung to collapse. The chest tubes placed after surgery are to prevent this from happening. The chest tubes drain fluid and air from around the lungs and are attached to an empty drainage box which will collect any fluid that drains out from the chest. When an air leak lasts longer than a few days, it is called a prolonged air leak. These leaks will heal but it means that the chest tube(s) will remain in place and the hospital stay may be longer than expected. At times, patients may go home with the chest tube(s) in place which will be attached to a Heimlich valve. (The large drainage box is removed and replaced by a heimlich valve). A home health nurse will make home visits to inspect the chest tube sites and change the dressings. Teaching prior to discharge from the hospital will be provided on how to check for an airleak from the chest tubes. Follow up with the surgeon should be scheduled as instructed or once the air leak has resolved.
• Urinary retention – temporary urinary retention, or the inability to empty the bladder, may occur after surgery. This complication may be caused by the anesthetic used during surgery, epidurals or pain medications given after surgery. Urinary retention is usually treated by replacing a urinary catheter to drain the bladder for a period of time until the patient regains bladder control. In some cases, patients may need to be started on medication to help empty the bladder. A urology consult may be requested for those who have ongoing issues with urinary retention. This problem usually resolves within a couple of days after surgery. Patients will not be discharged from the hospital until they have been able to urinate once the urinary catheter has been removed.
• Anesthesia reactions – allergies to anesthesia may occur, although this is rare.
• Prolonged leakage of fluid from the chest (which is usually temporary)
• Injury to the vocal cords which may lead to voice changes and is usually temporary. This may occur when the patient is intubated. The breathing tube that is inserted for surgery passes between the vocal cords. If there is an injury the patient may have hoarseness or difficulty with swallowing liquids, food and even saliva which may result in a cough. The risk due to a vocal cord injury is aspiration of liquids or food into the lungs which may result in pneumonia. Speech therapy may be ordered to perform a swallow study. This may either be done at the bedside or in the radiology department. The patient’s ability to swallow is assessed and the therapist will make further recommendations. If the symptoms are severe an ENT (ear, nose and throat doctor) may be requested to see the patient. Often times, the patient is placed on a specific diet and given instructions on how to eat and drink. These symptoms usually resolve in time.
• Heart attack
• Stroke
• Death – the most common cause of mortality are heart problems (heart attack, irregular heart rhythms) and or lung problems after surgery.

The average hospital stay is 2-3 days. Several factors may influence one’s hospital stay such as postoperative complications or side effects from the surgery (i.e. increased pain, nausea, vomiting etc). In preparation for discharge from the hospital, the social worker will assist in making arrangements for home health care if needed. Some patients need additional rehabilitation after surgery and may need to go to either inpatient or outpatient pulmonary rehabilitation. The surgical team and social worker will help make arrangements if this is necessary.