General patient information and advice for haemorrhoid surgery

General patient information and advice

Regardless of the type of surgical procedure, pre-operative discussions between the patient and their anaesthetist and surgeon should cover specific topics to ensure that the patient knows what to expect and what is expected of them. It is important to involve the patient in optimising their general medical condition as many patients undergoing surgery have significant co-morbidity. In advance of admission to hospital, the patient should visit their primary care physician or be referred to the appropriate hospital specialist, in order to stabilise their treatment for other medical conditions and to optimise their analgesic medication prior to surgery. Educational resources, such as www.youranaesthetic.info, can inform patients about their forthcoming anaesthetic procedure and provide specific advice about the different anaesthetic and pain relief techniques for surgery. The information can be downloaded as copyright-free printed leaflets suitable for distribution to patients, or patients can visit the site themselves. This resource also offers patients referenced advice and information about the risks of general and regional anaesthesia techniques.

Topics for discussion

• Pre-operative advice
  
  
  
  • targeted nutritional and dietary advice primarily for obese patients in the weeks prior to surgery – even a few kilograms of weight loss may improve anaesthetic management and postoperative rehabilitation
    
  • addition of roughage/bulk (e.g. cereals) to the diet to aid regular bowel movements – this is also important postoperatively
    
  • need to stop smoking
  
  
• Immediate pre-operative preparation
  
  
  
  • continuation, alteration or cessation of normal medication or need for fasting
  
  
• Choice of anaesthetic technique
  
  
  
  • regional or general anaesthesia
    
  • risks and benefits of recommended techniques on an individual patient basis
    
  • possibility of converting regional techniques to general anaesthesia
  
  
• Informed consent
  
  
  
  • provide adequate information regarding surgery, anaesthesia, and postoperative pain management, including benefits and complications
  
  
• Information on pain management
  
  
  
  • patient attitudes and expectations may be influenced by pre-existing pain and therefore must be assessed. Pre-operative anxiety has been demonstrated to be associated with increased pain after a variety of surgical procedures ((Brander 2003), (Caumo 2002), (Kalkman 2003), (Nelson 1998)), and therefore, assessment of pre-operative anxiety and provision of information on how to reduce anxiety are shown to be of benefit for reducing postoperative pain
    
  • pain management often involves a step-down approach from regional anaesthesia or systemic opioids to oral medication. For a successful outcome of pain management patients need:
    
    
    
    • information and training in the use of any objective pain assessment used after surgery, for example visual analogue scores
      
    • a realistic expectation of the intensity and duration of postoperative pain
      
    • demonstration and training in pain management techniques that require patient involvement (intravenous patient-controlled analgesia, patient-controlled epidural analgesia)
      
    • information about the medication to be used after hospital discharge for management of pain and postoperative nausea
  
  
• After surgery, patients should know what to expect with regard to:
  
  
  
  • location and size of the wound and dressings
    
  • intravenous fluids/blood transfusion/auto-transfusion equipment
    
  • possibility of postoperative symptoms, such as postoperative nausea and vomiting
    
  • when to return to normal oral fluids and nutrition
  
  
• Information on rehabilitation and physiotherapy should include:
  
  
  
  • approximate timetable for return to normal physical activities – both domestic and professional
    
  • advice for continuing rehabilitation following discharge and other postoperative care
    
  • explanation of the different types of rehabilitation, namely in-patient or out-patient
    
  • contact numbers for use after discharge and information on follow-up calls or clinic visits with the surgeon or care staff
  
  
• Information should be made available to the patient regarding care at home:
  
  
  
  • diet – high fibre foods add bulk and softness to the stool to reduce constipation and straining
    
  • hydration – drink plenty of fluids (this does not include coffee, tea or alcohol)
    
  • stool softeners – contain fibre to reduce straining during bowel movements
    
  • sitz baths – a 15 minute bath in tepid water, several times daily or as often as required
    
  • regular exercise

General patient assessment

The overall aim of patient assessment is to ensure that surgery is justified and that the risks to the patient from the procedure are minimised, especially in patients at high risk of surgical complications. Therefore, one of the most important considerations prior to surgery is the condition of the patient. This will determine the pre-operative precautions and medication required, as well as the choice of anaesthetic and operative technique. These decisions can be made in collaboration with the patient’s primary care physician, or within specialist pre-operative assessment clinics. Information resources such as postoperative pain guidelines may be useful: http://www.healthquality.va.gov/Post_Operative_Pain_Management_POP.asp(Rosenquist 2003) and http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp104.pdf (Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine).