Laparoscopy_ Bariatrics_ _ Surgery_ PA

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					Laparoscopy Surgery Aaron L. Cernero, D.O., P.A
Laparoscopic Bariatric Surgery Pre and Post Op Instructions
1) [ ] Say goodbye to and stop drinking carbonated beverages. This includes sparkling wines/waters/fruit juices, beer and champagne. Be aware of hidden carbonation in “Slushees” (found at the movies and some stores) and “diet limeade” (found at some drive-in fast food restaurants). [ ] Now is the time to stop smoking. This is extremely important for tissue healing. It’s also easier right now, because you will be on pain medicines to help with the jittery feelings and after surgery, you won’t be able to gain weight. [ ] Start taking a chewable vitamin, ONE children’s type, every day. [ ] Time to stop the “just a few beers (or drinks) a night”. Alcohol is very high in calories. Do you realize that 3 beers is more than 500 calories?

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***IF IT’S NOT ON THIS LIST-DO NOT EAT IT!*** DO NOT HAVE: Alcohol, beer, sugar sweetened drinks, fruit, bread or baked goods, rice, potatoes, pasta, tortillas, chips, oatmeal, cereals, Deep fried anything! Candy, cake, pie, cookies, ice cream, sugar. CARBONATED beverages.

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Liquid Diet
1) [ ] You are now to stay on liquids until surgery. This liquid diet helps prepare the digestive tract for surgery, helps shrink your liver and reduces surgical risks. You may include the following: “Isopure” (40 Gm protein/20 oz bottle) (Commercially prepared protein drinks) Apple, grape, cranberry (without added sugar) Water Tea Liquid instant beverages (without added sugar) Nonfat (ie, skim) or 1% fat milk Coffee (no cream) Low-fat creamy (eg, strained) soups Broth (chicken, beef, vegetable) Low-fat, low-sugar yogurt, pudding, or custard Plain Jell-o Sugar-free popsicles Sugar-free/Calorie-free drinks (NON-CARBONATED)  Protein (based on your current BMI)  BMI above 45 you need 60 or more grams of protein  BMI less than 45 you need 55-60 grams of protein 2) [ ] Stop taking the following medications 7 days prior: Aspirin, Coumadin, Heparin, or any blood thinners. If you need further instructions regarding your medications, please ask during your PreOp appointment. 3) [ ] Shop for your protein supplements, over the counter medications, chewable vitamins and 4oz. reusable/disposable containers (½ cup = 4 oz.). (See the sample list attached). Protein Supplement Criteria—When purchasing prepared protein drinks, please follow these guidelines, learn to read the labels. Do not be fooled by the packaging, look for the total carbs, etc. a. Calories-under 200 b. Protein-15+ is the best c. Low carb/sugar 2

Where to shop: Watch for coupons and specials on the supplements. User friendly places include, but are not limited to: GNC, Sam’s and WalMart (look in the pharmacy area for the supplements). If you find other friendly places, let us know and we will add them to this list. The Night before Surgery: 1) Nothing by mouth after midnight. This includes gum or mints. If you do, your surgery may be canceled. You may brush your teeth, but spit it out. 2) Medications[ ] Take your normal evening medicines the night before surgery [ ] Take only your blood pressure medicine the day of surgery with a sip of water:  Everything else can either be delayed or skipped that day. [ ] Oral Insulin diabetics: DO NOT take your morning dose of diabetes medicine. 3) Remove all fingernail polish. Artificial nails are fine-no polish. The Day of Surgery: 1) Take a good shower using an antibacterial soap (such as Lever 2000 or Dial). Do not use perfumed soaps. Wash your hair as usual. Do not apply any lotions or oils to your skin. Deodorant is fine. 2) Using a black permanent marker, make about a 2-3 inch line on your left & right side where your waist is. (Where your pants or trouser waist sits.) Women-also mark your bra line in the middle or between your breasts. These marks will give Dr. Cernero a “map” to be able to place the incisions and port in areas away from clothing irritation and discomfort. 3) Do not wear any make-up. 4) Leave your jewelry and valuables at home. 5) Wear loose, comfortable clothing. Something that will easily go on after surgery. Slip on shoes if possible. 6) You must bring someone with you to drive you home after surgery. It is your responsibility to arrange this prior to surgery. This person will also be receiving and signing off on your post-op instructions at the facility. 7) Once you are in the pre-op holding area, you will have an IV started in your arm and it will stay there until just before you go home. All of your medications will be administered through the IV until it is discontinued.

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8) The length of your surgery (including anesthesia time) is approximately 90 minutes. 9) You will be in the Recovery Room for about 90 minutes, or until you are awake and alert. Soon after surgery you will be given a swallow evaluation. You will be taken to your room where you will be staying over night. The next day you will receive your discharge instructions. The person taking you home will have to sign your instructions. ***YOU ARE NOW FIRST AND FOREVER A LAP-BAND PATIENT. ANY TIME YOU NEED TO GO TO THE EMERGENCY ROOM, HAVE SURGERY, OR ANY OTHER INVASIVE PROCEDURE, YOU MUST CALL DR. CERNERO AND LET HIM KNOW. HE MAY NEED TO DEFLATE YOUR BAND, OR GIVE SPECIAL INSTRUCTIONS TO YOU OR YOUR PROVIDER*** After Your Surgery: 1) Watch for the signs of infection: *Fever over 101 degrees; *excessive redness or drainage from any of your incisions. (An infected incision looks mean and ugly and is hot to touch and painful.) Call the office if this occurs. 2) You need to have someone stay with you for the first 24 hours after surgery. 3) Some people find it more comfortable to sleep in a recliner style chair for a couple of nights. Some people prefer their own bed. Figure out what works for you. 4) You may shower 48 hours after surgery. Just let the water flow over your abdomen. Do not use washcloths across the incisions, as this may introduce bacteria that can cause an infection. 5) No tub bathing for 2 weeks. 6) Your incisions are closed from the inside and covered with “steristrips” These are very adhesive tapes, and will eventually come off in about 10-14 days. DO NOT pull them off! Pulling at them can tear your skin. If they are curling at the edges, you may very carefully snip them with a nail clipper. 7) Women: Some women are more comfortable wearing non-underwire bras for awhile, such as a sports bra. 8) No hot tubs, swimming pools, lake, river or ocean water until all incisions are completely healed, about 4-6 weeks. 9) WALKING. Starting today, we want you to walk frequently. Do not over do the distance, but it is important for you to take a minimum of 20 steps at a time, 5-6 times/day. Laying around will increase your risk of pneumonia and blood clots. Walking increases your ability to absorb the gas, improve healing and energy. Keep in mind that you will be taking your pain medicine, which will 4

make you sleepy/drowsy. But between doses, we want you to start moving around. 10) No treadmills for 1 month-due to the risk of injury. 11) You may resume sexual activity in 3 weeks, or as tolerated. 12) Return to work: You may not work until after your 1 week post op check up. If your job is more sedentary, you can plan on returning after this visit. If your job is more physical, plan at least two weeks or more. Guidelines include: No lifting more than 10 pounds, no pushing, pulling or twisting motion for 2 weeks. 13) Driving: After you have been off your pain prescription pain medication for 24 hrs. 14) Keep your one week post op appointment. 15) Medicines: ONLY ONE PILL AT A TIME. WAIT 5-10 MINUTES BETWEEN PILLS. Take your medicines with warm liquids. All medication larger than an aspirin must be cut in half, crushed or liquid for two weeks. Mix the crushed medicine with juice, pudding, apple sauce, etc. DIABETICS: You need to be checking your glucoses 4 times a day (brkt, lunch, dinner, bed). Call if your glucoses are running >120. We will adjust your medications on an individual basis. Helpful over the counter medications:

(These will be helpful for the 1st couple of weeks after surgery and after adjustments later.)

Gas/Bloating: Constipation:

Diarrhea: Headaches: Sinus:

Gas-X chewable tablets Milk of Magnesia 1T with 4oz liquid, then every 15 minutes drink 4 oz liquid for the next hour. Use coffee, tea, juice, water as the liquid. DO NOT USE METAMUCIL, FIBERCON, CITRUCEL, OR ANY FIBER LAXATIVES! Only if it persists for more than 48 hours, use PeptoBismol. Follow the directions. DO NOT USE IMMODIUM. Liquid Tylenol, Tylenol Melt Aways, Liquid Motrin Liquid Guaifenesin (Robitussin-expectorant only) Follow directions.

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POST-OP PAIN: You have just had major surgery and you must expect some pain. Pain is a very individual situation. We rate pain on a scale of 1-10. 10= “the most severe pain you could experience, and you want to go to the emergency to get relief”. 1=”barely there and you can function around it”. We recommend using this scale to determine when to take your pain medicine. When your pain gets to a “5” it is time to take pain medicine. If you wait much longer, it will not work and you will play “catch-up”. Some people will have discomfort in their shoulders. This is because some of the gas (carbon dioxide) which is used to inflate your abdomen becomes trapped under your diaphragm and your brain thinks it is your shoulders. This discomfort can be pretty intense. If you do not have this discomfort by the evening of surgery, you won’t get it. Some people will have discomfort behind the breast bone and it is from the same reason. If the pain is intense enough, use your pain medicine. The best therapy for either of these two types of pain experience is moving around. Remember, we already talked about walking. As the next few days progress, most people notice that the pain is resolving. The one area most noticeable is usually the longer incision where your port is located. This area will be more tender for awhile-especially if you tend to sleep on your stomach or left side. Also, if you bend, twist or bump this area, you may feel a twinge of discomfort in your port site.

Pregnancy: Dr. Cernero discourages pregnancy during the first 24 months (or until you reach your goal) after weight loss surgery. It is dangerous for you and your baby. We recommend reliable forms of birth control during this time.

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FIRST FEW WEEKS POST OP BARIATRIC DIET PROGRAM
THE FIRST 48 HOURS POST OP: Drink only clear, thin liquids. If you can read the newspaper through it, you may have it: **”Isopure” (40 Gm protein/20oz bottle) **New Whey (25 or 42 Gm/tube) Apple, grape, cranberry (without added sugar) Water Tea Coffee (no cream) Broth (chicken, beef, vegetable) Plain sugar-free Jell-o Sugar-free popsicles Sugar-free/Calorie-free drinks (NON-CARBONATED) THE FIRST 2 WEEKS POST OP: Drink only thin liquids. Consume a low-fat, low-sugar, all liquid diet for the first 2 weeks. Sip 4oz to 6oz of liquids 12 times per day. Space these liquid meals 3 hours apart. Drink water between meals. “Isopure” (40 Gm protein/20 oz bottle) (Commercially prepared protein drinks are fine) Apple, grape, cranberry (without added sugar) Water Tea Liquid instant beverages (without added sugar) Nonfat (ie, skim) or 1% fat milk Coffee (no cream) Low-fat creamy (eg, strained) soups Broth (chicken, beef, vegetable) Low-fat, low-sugar yogurt, pudding, or custard Plain Jell-o Sugar-free popsicles Sugar-free/Calorie-free drinks (NON-CARBONATED) THE 3rd & 4th WEEK: If you feel ready (no nausea or vomiting), you may progress to “a soft diet” for 2 weeks. Slowly consume 1 oz of soft consistency protein food and 1 oz soft consistency carbohydrate food 6 times per day. Space these soft consistency meals 3 hrs apart. Drink water or other noncaloric, noncarbonated beverages up to 30 minutes before a meal or 60 to 90 minutes after a meal. Soft protein food choices: 7

Low-fat cheese (eg, cottage cheese, American cheese) Eggs or egg substitutes Chicken, egg, or tuna salad Chicken and turkey (eg, ground or shredded meat) Fish Moist Casseroles (usually made with a soup base) Soy products Beans Soft carbohydrate food choices: Crackers Hot cereal or cold, soggy cereal Mashed potatoes Fruit without the skin (eg, canned fruit, applesauce, or bananas) Well-cooked and easily digested vegetables (eg, potatoes-no skin, mushrooms, broccoli/cauliflower, spinach, & squash) DO NOT attempt to eat beef or pork products until after your first adjustment (fill) Give your stomach time to heal. Remember to CHEW! CHEW! CHEW! and always watch what you eat. THE 5th & 6th WEEK: Consume small amounts of solid foods. Slowly consume 2 oz protein food and 1oz to 2 oz of carbohydrates four to five times per day. Space these solid meals 3 hrs to 5 hrs apart. Chew all solid foods to a mushy consistency. Remember not to drink liquids during or shortly after the meal. Solid foods, as tolerated: Introduce pasta, rice, and red meats at separate times to see if they are tolerated. Avoid fibrous foods such as pineapple, celery, and nontender cuts of red meat. Avoid meat and other foods that are dry and overcooked. SUGGESTIONS TO HELP YOU THROUGH THIS WEEK: 1. You will be drinking all day long. This is fine. Keep hydrated. Aim for 64 oz/day, water (plain) should be half of this goal. 2. Take small sips, DO NOT gulp! Use a straw if it helps. 3. Maintain your protein levels. Add other protein supplements if you need to. 4. Begin each morning (forever) with warm liquids-nothing cooler than room temperature, this will help thin out mucus secretions, and decrease stomach spasms. You may add colder liquids afterward. 5. Use a chewable vitamin-forever. 8

6. Avoid high calorie drinks. It will slow down your weight loss and defeat the whole reason you went through this to begin with. 7. NO CARBONATED BEVERAGES-EVER!

IF YOU HAVE A SURGERY RELATED EMERGENCY, CONTACT OUR OFFICE AT 903-868-0133. YOU WILL BE INSTRUCTED WHERE TO GO FOR CARE. IF YOU ARE EVER INSTRUCTED TO GO TO THE EMERGENCY ROOM, PLEASE GO TO WNJ HOSPITAL.

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