Exploratory Laparotomy Background By definition, an exploratory laparotomy is a laparotomy performed with the objective of obtaining information that is not

available via clinical diagnostic methods. It is usually performed in patients with acute or unexplained abdominal pain, in patients who have sustained abdominal trauma, and occasionally for staging in patients with a malignancy. Once the underlying pathology has been determined, an exploratory laparotomy may continue as a therapeutic procedure; sometimes, it may serve as a means of confirming a diagnosis (as in the case of laparotomy and biopsy for intra-abdominal masses that are considered inoperable). These applications are distinct from laparotomy performed for specific treatment, in which the surgeon plans and executes a therapeutic procedure. With the increasing availability of sophisticated imaging modalities and other investigative techniques, the indications for and scope of exploratory laparotomy have shrunk over time. The increasing availability of laparoscopy as a minimally invasive means of inspecting the abdomen has further reduced the applications of exploratory laparotomy.[1] Nevertheless, the importance of exploratory laparotomy as a rapid and cost-effective means of managing acute abdominal conditions and trauma cannot be overemphasized. Indications Four primary indications for an exploratory laparotomy are noted, as follows. Acute-onset abdominal pain and clinical findings suggestive of intra-abdominal pathology requiring emergency surgery In these conditions, exploratory laparotomy is carried out both to diagnose the condition and to perform the necessary therapeutic procedure. Peritonitis Patients with clinical features of peritonitis may have pneumoperitoneum on erect chest and abdominal radiographs. They usually have a perforated viscus, most commonly the duodenum, stomach, small intestine, cecum, or sigmoid colon. Exploratory laparotomy is done first to determine the exact cause of pneumoperitoneum, followed by the therapeutic procedure. In the absence of pneumoperitoneum, appendicular perforation and intestinal ischemia are possible diagnoses; a high index of suspicion for possible intestinal ischemia should be maintained. Intestinal obstruction Patients with vomiting, obstipation, and abdominal distention are likely to have intestinal obstruction. Abdominal radiographs in these patients may reveal dilated intestinal loops and air-fluid levels. Hernia, especially an incarcerated inguinal hernia, should be ruled out as a possible cause of the obstruction. Intra-abdominal collections Patients with pain in the abdomen and fever may have intra-abdominal collections. These are usually detected by means of ultrasonography or computed tomography (CT) and can often be managed percutaneously. A persistently high aspirate or the presence of enteric contents may suggest perforation, and laparotomy may be required to control the source. Abdominal trauma with hemoperitoneum and hemodynamic instability Hemodynamically unstable trauma patients with hemoperitoneum should undergo exploratory laparotomy without any delay. They are likely to have intraperitoneal bleeding after injury to the liver, spleen, or mesentery. They may also have associated intestinal perforations that call for emergency repair. In patients with penetrating abdominal trauma (PAT), exploratory laparotomy was conventionally carried out to rule out intra-abdominal injury. The role of laparoscopy has been highlighted in a recent systematic review in patients with PAT.[2] Laparoscopy has been found to be useful in identifying diaphragmatic injury but has been

found less sensitive for detecting hollow visceral injuries. It is, however, very good for identifying the need for exploratory laparotomy. Chronic abdominal pain Availability of good imaging facilities have restricted the use of exploratory laparotomy in these conditions; however, when limited facilities are available, exploratory laparotomy becomes an important diagnostic tool. These patients may have intra-abdominal adhesions, tuberculosis, or tubo-ovarian pathology.[3] . Staging of ovarian malignancy and Hodgkin disease The role of surgical staging in Hodgkin disease is controversial, and recommendations are restricted to patients who may be considered for primary radiotherapy as the sole modality of treatment. [4] Obscure gastrointestinal bleeding The role of exploratory laparotomy has diminished over the last few years with the availability of good imaging, endoscopic techniques, and laparoscopy. However, in centers with limited facilities or when the bleeding is profuse, exploratory laparotomy, with on-table enteroscopy when indicated, can help identify the source.[5] Ambiru et al used exploratory laparotomy with capsule endoscopy, CT scanning, and mesenteric angiography for the diagnosis of ileal and ovarian varices in a patient with obscure gastrointestinal bleeding. [6] Contraindications The primary contraindication for exploratory laparotomy is unfitness for general anesthesia. Peritonitis with severe sepsis, advanced malignancy, and other comorbid conditions may render patients unfit for general anesthesia. Technical Considerations Exploratory laparotomy is sometimes a good diagnostic tool. However, anticipation of the diagnosis is necessary, and a hasty exploration should be avoided if the center is not well equipped to perform the therapeutic procedure that will be necessary if the suspected condition is confirmed. Nontherapeutic laparotomy is associated with significant long-term morbidity, including adhesive intestinal obstruction and incisional hernia. Consequently, exploratory laparotomy should be performed in accordance with standard protocols and guidelines for laparotomy. The authors have found that in equivocal cases of acute abdomen, diagnostic peritoneal lavage (DPL) is often helpful in determining the need for exploratory laparotomy. If DPL findings are positive, then an exploratory laparotomy is performed; if DPL findings are negative, the patient is closely monitored. [7] Preprocedural Planning The patient's physiologic status at laparotomy is an important determinant of outcome. Accordingly, whenever possible, efforts should be made to optimize the patient's general condition. This includes correction of fluid and electrolyte imbalances, blood transfusions, and bronchodilator nebulizations as required. Before the procedure, a nasogastric tube and an indwelling urinary catheter are inserted to decompress the stomach and the urinary bladder. Decompression of the stomach reduces the risk of aspiration of gastric contents during induction of anesthesia. The risk of such aspiration is high in these patients because of the emergency nature of the procedure and because of paralytic ileus. Decompression of the bladder reduces the risk that the bladder may be injured as the midline incision is extended inferiorly for better exposure. Equipment Exploratory laparotomy is performed in an operating room (OR). The OR should contain anesthetic equipment, overhead lights, electrodiathermy equipment, and suctioning systems. A standard laparotomy tray is usually sufficient for an exploratory laparotomy. If vascular intervention is anticipated, vascular instruments may be required. If major abdominal organ resection may be needed, appropriate instruments, facilities, and expertise should be available. Similarly,

abdominal trauma necessitates major abdominal surgery, for which appropriate infrastructure and expertise are required. Patient Preparation Patient preparation includes adequate anesthesia and appropriate patient positioning. Anesthesia Exploratory laparotomy is performed with the patient under general anesthesia. Patients who are anesthetized for emergency surgery are at higher risk for aspiration of gastric contents. Adequate care must be taken to empty the stomach before induction. Rapid-sequence induction considerably reduces the risk of aspiration.[8] Positioning The patient is placed in the supine position, with the arms abducted at right angles to the body. The lithotomy position may be employed instead when a pelvic pathology is suspected and a simultaneous vaginal or rectal intervention is necessary. Technique Exploratory Laparotomy After appropriate preparation (see Periprocedural Care), exploratory laparotomy is performed as follows. Midline incision and opening of peritoneum A vertical midline incision is the best choice: it affords a rapid entry into the peritoneum and is relatively bloodless and safe.[9] The incision may be made in the upper, middle, or lower midline, depending on the anticipated pathology, and may be extended in either direction if necessary. Exposure of the peritoneum should never be compromised in an attempt to keep the incision small. The skin is incised with a surgical knife. Electrocautery can be used instead of the traditional scalpel for making the incision, as skin incisions made by cutting diathermy are quicker, associated with less blood loss, and demonstrate no significant difference in the rate of wound complications, scar cosmesis, or postoperative pain.[10, 11] The incision is then deepened through the subcutaneous fat (see the image below). Electrodiathermy in coagulation mode provides a bloodless access through this layer. The linea alba is identified as a glistening layer deep to the subcutaneous tissues.

Upper midline incision. Incision is deepened through subcutaneous tissue to expose linea alba. The orientation of the fibers on the linea alba is appreciated; these fibers are directed medially and inferiorly from either side, and the midline is identified as the axis where they criss-cross. This is opened carefully by means of electrodiathermy or heavy Mayo scissors (see the images below).

Linea alba is divided to reveal preperitoneal fat. Abdominal incision is completed to reveal intra-abdominal organs. Every effort must be made to avoid injury to the intraperitoneal contents. This can be done by lifting the peritoneum in 2 straight artery forceps placed close to each other at right angles to the incision. Use careful palpation to ensure that no bowel or omentum is picked up in the artery forceps. In reoperations, extreme care is necessary because the underlying bowel may be adherent to the parietal peritoneum. In these cases, the peritoneum is opened in a virgin area, preferably by extending the incision appropriately. Exploration of abdominal cavity The steps of exploration depend on the initial findings and are governed by the principles of systematic survey and priority for life-saving maneuvers. Massive hemoperitoneum suggests 2 things. First, the patient may have a major source of bleeding. Second, the presence of blood within the peritoneum interferes with adequate exploration. The ideal strategy is to lift the small bowel and its mesentery out of the peritoneal cavity, to rapidly suction the blood within the peritoneum, and to place laparotomy pads in the 4 quadrants of the peritoneum. Once this is done, each pad is carefully removed to allow inspection of each quadrant. Identification of the source of bleeding is much easier in the absence of massive hemoperitoneum. Common sources include injuries to the liver (see the image below) or spleen, ruptured ectopic pregnancies, mesenteric tears, hollow visceral injuries, aortic aneurysms, and splenic or hepatic artery aneurysms. Once the source of bleeding is identified, necessary corrective measures must be taken.

Liver laceration in traffic accident victim who presented with hemoperitoneum. If enteric contents are the finding, they are suctioned out with a sump suction catheter, and the source of the enteric contamination is sought. This search must be performed systematically, starting from the stomach. The anterior aspect of the stomach is inspected for a perforation, followed by the duodenum. Subsequently, the small bowel is inspected carefully, starting from the duodenojejunal flexure. Each segment of the intestine is held up by the surgeon, and all surfaces are inspected. Any slough on the serosal surface is gently separated to allow identification of an underlying perforation (see the image below).

Laparotomy in patient with peritonitis. Image shows perforated duodenal ulcer. If no source of enteric contents is found in the small intestine, the appendix and then the colon are examined. Any perforation found in the intestine is controlled. Methods of controlling the source include direct repair, buttressed repair, resection, and anastomosis or exteriorization of the perforation with stoma formation. The choice between the different options depends on the site of perforation, the suspected pathology, the extent of the disease, and the patient's physiologic status. In patients with intestinal obstruction, possible findings on exploratory laparotomy include adhesive intestinal obstruction, a single intraperitoneal band with intestinal compression or torsion, and tumors (see the images below).

Laparotomy in patient with intestinal obstruction. Intraoperatively, single

peritoneal band causing intestinal obstruction was found. Laparotomy in patient with acute intestinal obstruction. Sigmoid volvulus with gangrene was found intraoperatively.

Multiple omental deposits in patient with disseminated carcinoma of stomach.

Multiple metastatic deposits over small bowel in patient with colonic malignancy. Staging laparotomy should include a thorough search for foci of malignancy, splenectomy, wedge and core liver biopsies, and sampling of retroperitoneal lymph nodes. In premenopausal women, oophoropexy is performed in anticipation of radiotherapy. Completion and closure Placement of drains after an exploratory laparotomy is still a subject of debate. The evidence currently available is inadequate to support routine drain placement. Patients with extensive contamination may benefit from drains in the subhepatic space and the pelvis.[12] Once the procedure is completed, the abdominal wall is closed. Before closure, however, the instrument and pad counts must be double-checked. The surgeon should manually inspect the peritoneum for any retained pads or instruments, even if scrub nurse has found the count to be correct. Closure is carried out with either nonabsorbable suture material (eg, polypropylene) or a delayed absorbable suture material (eg, polydioxanone) in either a continuous suture or interrupted sutures. The standard approach is to place sutures about 1 cm from the edge of the incised linea alba, maintaining a distance of 1 cm between successive bites. Sometimes, the Smead-Jones closure technique (ie, single-layer mass closure) may be employed to close the abdomen if the abdominal wall is plastered and separate layers are unavailable as a result of previous operations. This technique makes use of figure-eight sutures.[13] At times, closure may be rendered difficult by an edematous or distended bowel. In such circumstances, forced closure may have adverse postoperative outcomes in the form of impaired ventilation, intra-abdominal hypertension, pain, and dehiscence. Laparostomy and delayed closure may be a better option in such cases.[14] Complications of Procedure An exploratory laparotomy is associated with the same complications that are associated with any laparotomy. Immediate complications include the following:

Paralytic ileus Intra-abdominal collection or abscess

Wound infections Abdominal wall dehiscence Pulmonary atelectasis Enterocutaneous fistula Delayed complications include the following: Adhesive intestinal obstruction Incisional hernia Exploratory Laporatomy What is Exploratory Laparotomy? It is an operation where a cut is made into the abdomen. It is a method of to explore the abdomen, a diagnostic tool that allows physicians to examine the abdominal organs. Purpose It may be recommended to a patient who has abdominal pain of unknown origin. In addition, bleeding into the abdominal cavity is considered a medical emergency such as in ectopic pregnancies. It is used to determine the source of pain and perform repairs if needed. Exploratory laparotomy may be used to examine the abdominal and pelvic organs (such as the ovaries, fallopian tubes, bladder, and rectum) for evidence of endometriosis. Any growths found may then be removed. Complications Bleeding Infection Failure to find the cause of the problem; more surgery or other treatments may be needed Poor healing of the incision Damage, injury, or problems with the bowels Risks of anesthesia What to expect before the procedure Your doctor will do pre-operative evaluation in the clinic 1 week before the procedure (if not an emergency case). You may need to undergo some routine tests before your operation e.g heart trace (ECG), x-ray and blood tests for cardio-pulmonary clearance. You will be admitted a day before the scheduled procedure. Consents must be secured Nothing by mouth for 8 hours prior to the time of the procedure If ordered by the physician, cleaning or fleet enema will be given for further bowel preparation. Insertion of Intravenous Line Diagnostic exams as ordered by the physician like Complete blood count, blood typing, urinalysis and ultrasound. Pre-operative medicines and antibiotics will be administered. Instructions regarding change of gown, removal of jewelries, dentures, contact lenses, hair accessories, nail polish and make up will be given. An hour before the scheduled operation, you will be wheeled down to the delivery room. Abdominoperineal prep (shaving) will be done. What to expect during the procedure Prior to the time of operation, you will be wheeled in to the operating room where a surgical nurse will do the necessary preparations such as placement of cardiac leads, hooking to the cardiac monitor, oxygen administration thru nasal cannula, and placement of leggings. Your obstetrician will probably meet you in the operating room where an anesthesiologist will be ready. Prior to the procedure, for verification that the right patient and right procedure will be done, Signing in will be called, wherein you will be asked to state in your full name, date of birth, name of your surgeon and anesthesiologist, as well as the procedure to be done. After the introduction of anesthesia, a curtain will be raised over your mid section and you arms will be outstretched in order for the anesthesiologist and nurse to have access to your I.V.

A Foley catheter will be inserted. This is not a painful procedure, and if you have an anesthesia in you won't feel it at all. Then the surgical nurse will clean the incision site with betadine. Once an adequate level of anesthesia has been reached, the initial cut into the skin will be made. The surgeon will then explore the abdominal cavity for disease. Alternatively, samples of various tissues and/or fluids will be removed for further analysis and will be sent to the laboratory for microscopic examination. The surgeon will then close the incision. What to expect after the procedure After the operation, you will be wheeled into recovery where you will be observed for two hours as the anesthetic wears off. You will be hooked to the cardiac monitor to check your vital signs, and you will also be hooked to the oxygen. Post-operative medicines will be given to you. Depending upon the nature of your surgery and your doctor's assessment of your pain, you probably will be given a pain drip to address the pain. The foley catheter will remain until further orders. After the recovery period, you will be transferred to your room if there are no complications. Turning from side to side is advised. An abdominal binder is applied to support your cut. Eat nothing per mouth or take only sips of water or clear liquids or as ordered by your physician on the first day of operation or until flatus passed out. Discharge instructions and wound care will be given to you by your bedside nurse. At home: During the first two weeks, avoid tiring activities such as lifting heavy objects. Slowly increase your activities. Begin with light chores, short walks, and some driving. Depending on your job, you may be able to return to work. To promote healing, eat a diet rich in fruits and vegetables. Try to avoid constipation by: o Eating high-fiber foods o Drinking plenty of water o Using stool softeners if needed Take proper care of the incision site. This will help to prevent an infection. Follow your doctor's instructions When to call your doctor After you leave the hospital, contact your doctor if any of the following occurs: Fever or chills Redness, swelling, increasing pain, excessive bleeding, or any discharge from the incision site Increasing pain or pain that does not go away Your abdomen becomes swollen or hard to the touch Diarrhea or constipation that lasts more than 3 days Bright red or dark black stools Dizziness or fainting Nausea and vomiting Cough, shortness of breath, or chest pain Pain or difficulty with urination Swelling, redness, or pain in your leg Postoperative Instructions for Exploratory Laparotomy PLEASE READ THESE INSTRUCTIONS BEFORE YOUR SURGERY

DAY BEFORE SURGERY: 1. Please start a clear liquid diet at 12 pm the day prior to surgery. Only Jell-O, juice, broth, coffee, tea, water, etc. should be consumed.

2. You will most likely need to clean your bowels prior to surgery. Your physician will instruct you on the medication to take in order to complete this. 3. If you need to clean out your bowels, you will need a prescription for potassium tablets. Please also pick up the prescription at your pharmacy and take them as directed (one tablet at 4PM and another at 8PM). It is also suggested to purchase some over the counter topical medication for rectal irritation (e.g. Balmex or barrier creams). 4. It is generally best not to plan to do too much the day of the bowel preparation. Most patients should plan to take off work that day and stay near the bathroom. 6. In general you will be instructed to stop eating and drinking at midnight the day before surgery. DAY OF SURGERY: 1. Before Surgery a. You will be escorted to the Pre-operative care unit and given instructions of what to do with your belongings (leave all valuables at home) b. A nurse will interview you c. An IV will be started 2. During Surgery a. Your family will wait in the Surgery Waiting Room b. They will leave their cell phone number so that we can easily contact them during or after surgery if necessary c. After surgery, your physician will come to the waiting room to talk to the family to let them know that everything went well. If they are not present at that moment your physician will call their cell phone. 3. After Surgery a. You will wake up in the recovery room, where you will be checked frequently, and then be transferred to a post surgical unit b. You generally will have a tube in your bladder (foley catheter) to drain urine c. You will have compression hose on your legs to help with circulation and prevent blood clots d. You may have an oxygen tube placed under your nose to help wake up e. You may have a PCA (pain medicine pump) or you may be required to ask for pain medicine as needed. Do not wait until you are in a lot of pain to ask for this. f. Medications will be available for any nausea. Please ask for it as needed. g. Your home medications may be restarted according to your doctors orders h. Each day your nurse will: i. Check your incision ii. Check for vaginal discharge iii. Check your temperature, blood pressure, and pulse 4. Activity a. Immediately after the surgery your nurse will encourage you to turn, cough, and take deep breaths frequently. The nurse will instruct you how to support your incision during these coughs to decrease the pain. This is to prevent lung problems like pneumonia. b. You will be asked to use an incentive spirometry device- this is a small bottle that you slowly inhale as deep as possible to re-expand your lungs.

c. Use of incentive spirometry device and early ambulation will be VERY IMPORTANT to prevent postoperative fevers, pneumonias, and also will help with bowel functioning. 5. Diet a. You may be asked to not eat anything for the first day or two if your surgery was via a large incision. FIRST DAY AFTER SURGERY: 1. a. b. c. d. e. 2. a. b. c. The following will probably be removed Dressing/bandage Oxygen Catheter (unless you had surgery on your bladder or had a radical hysterectomy) Pain pump Your IV fluids may be slowed down or stopped once you are taking fluids well Treatments and Medications Medications are available for gas pains and nausea You will receive oral pain medication if you are tolerating fluids Your nurse will continue to monitor: i. Your incision ii. Any vaginal discharge iii. Your temperature, blood pressure, and pulse iv. The amount of fluids you take in as well as the amount of urine you are putting out

3. a. b. c. d.

Activity Continue to turn, cough, and take deep breaths You will be assisted up to the bathroom and helped with deep breathing exercises A pan will be provided to place over the toilet to measure your urine You will be encouraged to get up to the chair and walk in the hall at least four times every day (this helps your bowels to wake up and begin functioning). An abdominal binder may also be given to you to help support your incision during coughing or walking and to decrease the pain. If you had particularly extensive surgery or if you have had difficulty with walking even prior to surgery, physical therapy will be called to help with strengthening and walking. 4. Diet a. You will start with sips of water or ice chips. Subsequently when your bowels begin to make sounds and your nausea passes clear liquid diet (broth, jello, juices) will be started. If after starting clear liquid diet you begin feeling very full or nauseated, please stop drinking until your symptoms resolve and you talk to a physician or a nurse. When you begin passing gas per rectum full liquid diet or soft diet of your choice may be started. Passing gas per rectum is the first sign that your intestines have begun to function. Bowel movement, however, may not happen for up to five to seven days after the surgery. SECOND DAY AFTER SURGERY UNTIL DISCHARGE: 1. Treatments and Medications a. Your nurse will continue to monitor: i. Your incision

ii. Any vaginal discharge iii. Your temperature, blood pressure, and pulse iv. The amount of fluids you take in as well as the amount of urine you are putting out b. Your IV will be capped or taken out if you are tolerating your diet c. The bladder catheter will be removed (unless you had bladder surgery) d. You may receive medications (pill or suppository) to help your bowel function recover 2. Activity a. You should be up walking the halls as much as possible, but at least four times a day. b. Your nurse will begin showing you how to care for your incision to prepare for going home. c. Generally you will be able to shower second day after surgery. You will be instructed to let water and soap flow down the incision and then to pat it, not rub it dry. Until you are able to take a shower nurses will assist you with sponge baths. 3. Diet a. Your diet will be advanced when you have passed gas or had a bowel movement. Continue to drink plenty of liquids. 4. Teaching a. This is the time to ask questions about going home- please let your nurse know if you do not have help at home. b. Your nurse will instruct you on i. Activity ii. Driving iii. Lifting iv. Caring for your incision 5. Discharge a. You will be discharged from the hospital in general when: i. You are tolerating soft diet ii. You have either passed gas or had a bowel movement iii. You have been without fever for >24 hours. WHAT TO EXPECT AT HOME: 1. Pain Pain is to be expected at home but will continue to decrease over time. You will be given a prescription at discharge for oral pain medication. Use this as needed. a. Unless your doctor has instructed otherwise, it is ok to take the following in addition to your pain pills: Motrin (ibuprofen, advil)- 400-600mg every 6 hours. b. Narcotic pain prescriptions or refills will not be called in to a pharmacy on weekends, or after 5pm during the week. 2. Routine Medications a. Medications you were taking prior to surgery should generally be resumed as directed on your discharge from the hospital. 3. Vitamins and Iron Supplements

a. These can be purchased over the counter. Please let your physician know if you are planning to start any new vitamin or herbal supplementation. 4. Incision Staples a. These should be removed 10-14 days after your surgery if you have a vertical skin incision. For transverse skin incisions these are usually removed 3-4 days after surgery. You should call our office to make an appointment with our nursing staff for staple removal. b. If you have sutures (stitches) these will generally dissolve on their own and do not require removal. If you still have some that havent dissolved at your post-op checkup, let your doctor or nurse know so that they can be removed. 5. Incision Care Abdominal surgery, laparotomy, or abdominal hysterectomy: a. Clean incision daily with clean cloth and soap and water b. Staples will be removed 10-14 days after surgery c. Steri-strips (small tapes) may wash off in the shower. If they are still present after 5-7 days, you may peel them off carefully. Drainage or redness around your incision or a fever of >100.4 F should be reported to your doctor or nurse 3. Postoperative check up a. Unless instructed differently by your physician you should call our office to schedule your first postoperative visit two weeks after your surgery. 4. a. b. c. Hygiene Showers are acceptable You may shampoo your hair. It is ok to wash the incision gently with a clean cloth and soap and water.

5. Exercise (each procedure is different but these are general guidelines) a. No lifting of heavy objects (10-15 lbs) until after your post-op checkup b. Bending and stretching are ok unless it hurts (you may be putting too much strain on your incision if this is the case) c. Walking is encouraged, you will get fatigued faster than usual however d. Stair climbing is ok, but use caution e. Avoid vigorous exercise until after your post-op appointment 6. Activity a. Driving after major surgery should be avoided for 2 weeks, until reflexes have returned to normal, you can comfortably wear a seat-belt, and you are no longer taking prescription pain medication. b. Fatigue is common for 8-12 weeks after surgery; after all, your body has undergone the equivalent of a marathon. c. You should generally avoid sexual activity for at least 6 weeks and until after your post-op checkup. d. Light vaginal bleeding or pink/brown discharge is common for 2-4 weeks following a hysterectomy or vaginal procedure. e. If it hurts, you probably shouldnt do it 7. Bowel Function a. Bowel function often takes several weeks to return to normal; due to anesthesia, narcotic pain medications, and surgery on the intestines.

b. For constipation lasting a day or two: i. Milk of Magnesia, or mild laxative of choice is ok. c. For difficulty with gas pains: i. Walking ii. Dulcolax (bisacodyl) suppository or glycerin suppository d. Diarrhea i. Immodium or Pepto Bismol is ok ii. If severe diarrhea (8-10 stools per day) then please contact your doctor e. Stool softeners (colace, surfak, etc) may be used at your discretion f. If any symptoms are lasting longer than 2 days, please call your doctors office. 8. Return To Work a. This will be discussed at your post-op visit. As a general guideline, allow 2 weeks after laparoscopic or robotic surgery and 4-6 weeks after major abdominal surgery. If you would like to return to work sooner, please call our office. 9. Complications a. Please call the office at 858 455- 5524 if you experience any of the following: i. Fever greater than 100.4 ii. Unusually heavy bleeding iii. Uncontrollable nausea, vomiting, or diarrhea iv. Redness, tenderness, or swelling in one or both calves of your legs. If you are calling after office hours, please leave a message and your phone number on our emergency line and the physician on call will immediately contact you. 10. Home Nursing (Home Health Care) a. Home nursing may be used in the following situations: i. Open wounds ii. Home IV antibiotics iii. Unusual complications iv. Hospice