Tahbso.pdf

Recovering from total abdominal hysterectomy - bilateral salpingo-oophorectomy and omentectomy

We dedicate this book to all of the women who have entrusted their care to us. By allowing us to take part in their surgery and after care, they have shared an important time in their lives with us and taught us a great deal.

Contributors: Physicians: Dr. L. Elit, Dr. F. Moens, Dr. J. Mazurka Nurses: Betty Anne Lane, Tracey Mullen, Heidi Thomas Medical Secretary: Joanne Ricciardone Patient Education Services, Hamilton Health Sciences

© Hamilton Health Sciences, 2006 and 2010.

Table of Contents Page

Part 1: Learning about this condition ..................................... 3 - 16

Part 2: Learning about your hospital stay and your health care team ................................................ 17 - 28

Part 3: When you go home ................................................... 29 - 35

This book contains the answers to the most common questions women have about total abdominal hysterectomy – bilateral salpingo-oophorectomy and omentectomy. It also provides information to help you recover in the hospital and at home. This book will not replace talking with your caregivers, but may make it easier. Please share your concerns with us, write down questions you wish to ask the Health Care Team.

Questions: ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

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Part 1: Learning about this condition

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What is a total abdominal hysterectomy – bilateral salpingooophorectomy and omentectomy? There are 3 parts to this surgery: 1. A total abdominal hysterectomy, or TAH, is the removal of your uterus or womb. The cervix is also removed. 2. Bilateral salpingo-oophorectomy, or BSO is the removal of your tubes and ovaries. 3. Omentectomy which is the removal of the omentum. The omentum is an apron of fat which covers the other organs in the abdomen.

Why do I need surgery? This surgery is needed whenever there is a pelvic mass or growth. Often the cause of the pelvic mass is not known until after the surgery. After the surgery a doctor called a pathologist examines the tissues of the mass under the microscope. Only then can we be sure if it is cancer or not.

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Your doctors and other health care providers will discuss all treatment plans with you. They may use these words to describe what you have: Tumour which is an abnormal growth or mass to describe what you have. This does not mean that you definitely have cancer but is a word used to help describe what is going on. Benign means that it is not cancer. Malignant means that it is cancer. If the tumour is not cancer, the surgery will be the only treatment you will need. If the tumour is found to be cancer, you may need to have further treatment such as chemotherapy or radiation. Each person’s treatment plan is different so that you can get the best results possible.

What is the reason for my surgery? There are two main reasons for surgery. The first is to find out what the abnormal growth or mass is and in what organ it started.

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The second reason is to allow for the removal of as much of the mass as possible. Tumour cells are very tiny (microscopic). If cancerous, some may have spread to the nearby organs. To reduce the risk of spread, the surgeon will remove those organs as well. That is why, even though the tumour may have started on the ovary, that the uterus, tubes and omentum are also removed. When the operation is complete, the surgeon will check the liver, spleen, diaphragm and all the surfaces in your abdomen. This is to see if these organs are healthy. For this reason, your incision may be an up and down line from the pubic hairline to several inches above the belly button. Blood tests can be done to find out more about your mass. In most cases, blood tests cannot identify a cancer but will show how well the body is functioning.

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What fills the empty space when everything is removed? Normally, the uterus, ovaries and tubes fill a space in your lower abdomen about the size of your hand. The small bowel or intestines are just above. After a TAH-BSO, the intestines will dip down to fill the space.

Will I have to take hormones after my ovaries are removed? There is no single answer to this question. During the years when you can have children, you produce hormones each month. They prepare your body for pregnancy and also maintain the health of your bones, vagina and breasts. If the ovaries stop working early either through surgery or in menopause, you will no longer produce the same amount of hormones. This may lead to side effects such as hot flashes, thinning of the bones or dryness in the vagina. Changes made to diet and lifestyle can help lessen some of these side effects or you may choose to take hormones.

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There are times when a doctor would not recommend hormones. There is some evidence that certain cancers or medical conditions get worse when taking hormones. There are non-hormone medications that can be prescribed to ease the symptoms of menopause if you need them. Therefore it is very important to discuss all these issues openly with your nurse and doctor to make the best decision for yourself. If you cannot or choose not to take hormones: • For vaginal dryness, use a water-soluble lubricant such as K-Y Jelly and spend more time becoming aroused before intercourse. • To keep your bones strong, walk or exercise briskly for 20 minutes – 3 times a week. Be sure to maintain a healthy well balanced diet and limit salt, alcohol and caffeine to help keep your bones healthy and strong. Also, talk to your family doctor about scheduling routine bone density exams.

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When will I know if I have cancer or not? You and your family may want to know the answer to this question as soon as possible. If fluid is removed from the abdomen and cancer cells are found in it, the condition is known to be a cancer. During the operation, it may be possible to tell from what the mass looks like whether or not it is a cancer. However, to be completely sure the mass is cancer, it needs to be looked at very carefully under the microscope by a specialist called a pathologist. This examination usually takes up to 2 weeks.

What does it mean if there is cancer left inside after the surgery? Surgery is done to remove most if not all of the tumour. Sometimes, this is not possible. Both cancer of the ovary, tube and cancer of the peritoneum (lining of the abdomen) are like this. Sometimes, because the tumour and organs are stuck together, it is too difficult to separate them for removal. Other times, tumour seedlings are scattered over such a large area that it is next to impossible to remove them.

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In these cases, your doctor will recommend chemotherapy or radiation to shrink or kill any remaining cancer cells. Further surgery, if needed, is done at a later date.

How long will I be in hospital? A usual hospital stay is about 3 to 5 days. This is just an estimate. Your hospital stay may be longer or shorter than this. When the doctors feel you are ready, you can go home.

How long does recovery take? Total recovery has 3 parts: physical, emotional and sexual. These 3 parts of the recovery period may happen at different times.

Physical Physical recovery includes healing of the skin incision and return of energy. This can take 6 to 8 weeks. At the end of this time, most women will be back to their usual work and social activities.

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Emotional Emotional recovery means adjusting to the shock of having a cancer, being away from home and believing you can become well again. It also means feeling comfortable with yourself and the changes in the appearance of your body after your surgery. Emotional recovery may happen at the same time as physical recovery, or it may take longer.

Sexual Sexual recovery involves a return to your previous patterns of lovemaking, or making changes that fit with your partner’s and your needs. The outer sexual organs, the vagina and the brain (your most important sexual organ) remain the same. So does your normal, human need to feel loved and cared for.

If you would like, we can talk with you about positions and activities that can help you and your partner enjoy a comfortable relationship. The length of time for this recovery varies, but it is possible with patience and care. It can take 1 to 3 months, but it is not unusual for it to take longer.

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What changes will there be sexually? Most women report few sexual changes as a result of this operation. Healing of all incisions usually takes 6 to 8 weeks. After that, it is possible to start having intercourse again. Of course, affection and touching are possible before that time if the couple wishes. This surgery will not change the woman’s ability to have satisfying sexual relations or change her level of interest in sex. Women may notice the following changes: • The vagina may be shorter in its relaxed state, if the top section has been removed with the uterus. As the vagina is very stretchy, most people cannot tell the difference during lovemaking. In the “aroused” state, the vagina naturally lengthens. • The operation should not affect your ability to have an orgasm or sexual climax. However, a climax causes muscle contractions in the uterus as well as other parts of the body. Since the uterus is no longer there, some women have said there is a slight difference in their orgasms.

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• If menopause had not previously started, it will now. Many women find the vagina does not get as wet as it did before menopause. It is therefore a good idea to spend more time becoming aroused while making love so the vagina can be ready. It also helps to use a water-soluble lubricant such as K-Y Jelly. Oil based lotions and Vaseline will not flow freely out of the body and should not be used. • A cancer diagnosis and surgery can be stressful. If you have been tired, anxious or worried, you may find that your interest in sex is less. Talking to your partner or health care providers along with time and patience will often help your sexual feelings return. By 6 months, most women report a return to their usual lovemaking.

Will I have a lot of pain? This is a common concern. However, the more comfortable you are, the quicker you will recover. Comfort also allows you to take an active part in getting well again. During your pre-op visit, the anesthesiologist will talk to you about pain control. There are 2 main types of pain control used after surgery.

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The first is called Patient Controlled Analgesia, or PCA. It consists of a mechanical pump that delivers morphine by intravenous (IV) when you push the button. There is a dose and time limit set on the pump so you do not have to worry about giving yourself too much morphine. As well, when morphine is used to control pain after surgery there is no need to worry about becoming addicted to it. You will find that you may use it a lot the first day or so and then less each following day. Patients usually have a PCA for 2 to 3 days.

The second type of pain control is an epidural. The anesthesiologist places a tiny tube into your back area during surgery. The tube is then taped to your back and over your shoulder. A special pump will then deliver medication continuously so that you will feel less pain in the surgical area. Some patients have slight numbness or heaviness of one or the other thigh/leg. This is normal and will be closely watched by the nurses. This gets better when the epidural is taken out. You will still be getting up and walking with the epidural in place after surgery. Patients usually have an epidural in for 2 to 3 days.

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Part 2: Learning about your hospital stay and your health care team

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This part of the book describes your care in the hospital. The goal of care is to help you recover and to prepare you for going home. A number of people will be involved in your care. They are all part of your health care team. The most important person on the team is “you”! You will take part in your care too. A team needs to work together.

Who is my main doctor? I have met so many … Your main doctor is a specialist called a Gynecologic Oncologist. One of his/her roles in your care is to coordinate other medical specialists so that you get the best possible care. These doctors may look after women who need their surgery skills, but do not have cancer. At the Cancer Centre, the Gynecologic Oncologist reviews your medical history to get a full picture of your situation. Before your surgery and depending on your needs, he/she may ask other doctors to see you. These doctors are from: Anesthesia, Respirology or Internal Medicine. When you leave the hospital, a Gynecologic Oncologist will see you regularly for a length of time to make sure that your treatment has been complete.

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Who does my surgery? A team of Gynecologic Oncologists does the surgery. Everyday while you are in the hospital, one of the members of the team will see how you are doing and plan your treatment. Your treatment plan is reviewed with other doctors and nurses. The team also works with social workers, nutritionists and physiotherapists to make sure you get all the care you need.

How will the nurses help my recovery? Nurses will be available to guide you every step of the way. They will prepare you both physically and mentally for your operation, recovery and going home.

What should I expect before surgery? Planning ahead It is also important to plan for your healthy recovery before surgery. Be sure to get groceries and banking done a few days before hand.

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Also, arrange for help with meals, child care, pets, gardening and housework because rest is most important for the first few weeks after surgery. Be sure you have someone to drive you where you need to go during this time as the doctor may not advise driving for a while. Pre-op Clinic Up to 2 weeks before your surgery you need to have a Pre-op Clinic visit. There, the nurse will review your surgery and ask you specific questions about your health. You will have blood taken as well as a chest x-ray. An EKG (electrocardiogram) may also be done to check your heart. The team needs this information to plan your care. The information is also helpful to see your progress as you heal. The nurse will also review with you: • The consent form you signed at the doctor’s office • How to clean your bowels out • When to stop eating and drinking • What medications you take the morning of your surgery • What tubes and drains you may have right after surgery such as a urinary catheter – a soft tube in the bladder to drain urine into a bag

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The pre-op nurse will also teach you the deep breathing and coughing exercises that you will need to do after surgery. Doing these will help you keep your lungs healthy and reduce the risk of pneumonia-see page 26. You may want to practice these before your surgery. Just before surgery • have a shower or bath • remove nail polish from fingers and toes • remove all jewelry including body piercing

On the day of your surgery On the day of surgery, you will go to Same Day Surgery. This is Ward 592 at the Juravinski Hospital. There they will take your belongings and put your name on them and take them to the area you will be staying after surgery. It is important not to bring anything of value (money or personal). All rings and jewelry must be taken off before surgery, so it is best to leave them at home or with a family member for safekeeping. You will change into a hospital gown, empty your bladder and remove your dentures and contact lenses if you wear them. An intravenous, or IV will be started to give you fluids and some medications that are needed before, during and after surgery. You may receive some medication to make you sleepy.

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Once these preparations are completed, you will go to the holding area about one half hour before your surgery. Usually, one person may stay with you at that time. We cannot be sure of the exact time of your surgery. The time may be slightly earlier or later than planned. Once you go in to the operating room, your family members can wait in the waiting room to talk to the surgeon after the operation. If your family wishes to speak to the surgeon after surgery, please let your surgeon know this. After the surgery, you will go to the recovery room where the nurses will look after you. When you are fully awake, you will go to the ward to complete your recovery. As routine, some women go to the Intensive Care Unit (ICU) after the surgery. Your doctor will tell you if this is necessary.

What should I expect after surgery? As you recover from your operation, the nurses will provide the following care: • Review your pain control options with you to help maintain your level of comfort. Remember, pain is an individual experience and cannot be compared to others.

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• Watch for drainage from the incision after surgery. It is not unusual to have the dressing removed the next day and left uncovered. Usually there is only a small amount of reddish pink drainage from your incision. • Check for vaginal bleeding. A pad is worn to check this and for comfort. • Change your dressing as often as needed to promote healing. • You may use ice chips soon after surgery to keep your mouth moist and to help prevent nausea. The next day you will receive clear fluids and gradually increase your diet as your bowel function returns. • Maintain your IV. IV fluids are needed until you are drinking enough to meet your body’s needs. As well, an IV provides a way for the nurse to give you medications to help prevent nausea, heartburn, itching or antibiotics if needed. • Encourage you to do the leg and breathing exercises every 2 hours while awake. On the day after surgery, your nurse will help you get out of bed and into a chair. You will start walking short distances and your nurse and other members of the health care team will urge you to increase your activity a little each day. They will show you how to support your abdomen when getting out of bed so you do not put any stress on your incision.

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• Clean and care for the bladder catheter tube until your bladder can work normally again. The catheter is in place for about 24 to 48 hours. • Give you a warm blanket for your abdomen. Bowel activity is slow at first and many women feel bloated and have “gas pains”. Pain medication helps but walking is most effective to help get the gas moving and ease the discomfort. • Give stool softeners so your bowel movements will be soft and easy to pass so as not to put added strain on the incision area. • Give a medication called Heparin by needle in your upper thighs to help prevent blood clots from forming. This medication will be stopped as soon as you are walking regularly.

The nurses plan your care according to your individual needs. We encourage you to help plan your care. We are happy to answer any questions regarding your care and hospital stay.

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For several days after your surgery, your activity will be less than normal. During this time, your lungs breathe more shallowly at rest. Fluid build up may occur in the lungs. This could lead to complications, therefore it is very important to do the following: Breathing exercises 1. Take a slow deep breath and fill your lungs. Hold the breath for a count of 3. Slowly blow out. 2. Repeat 8 to 10 times each hour. 3. Cough 3 times after your finish deep breathing. Remember to hold your incision with a pillow or folded blanket.

Change your position every 2 hours. Lie on alternate sides, change the height of the bed or sit up in a chair.

Walk You must walk several times a day to regain your general strength. A nurse or family member can help you push the IV pole. Increase the number of times you walk as well as the distance each day.

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How important is nutrition? Nutrition plays a major role in your recovery. Healthy eating can help give you energy and strength. A balanced diet of protein, fruit, vegetables and whole grains will help your body heal. Your diet can also prevent problems with constipation. Eat foods with fibre such as bran, whole grains, fruits and vegetables to keep your bowels healthy and regular. If you have any questions about your diet, please write them down and ask your nurse or doctor.

What does the Social Worker do? The social worker supports your emotional and financial concerns. A new diagnosis of cancer and treatment can be frightening. Patients and families often have very strong and upsetting feelings at this time. The social worker can help you recognize and express those feelings. Sometimes the illness and recovery can affect your role in the home, either as breadwinner, spouse or caretaker of older parents, or dependent children. The social worker is aware of the turmoil this creates in the family and can support you in finding other sources of help.

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During your hospital stay and recovery, you may be entitled to sick benefits either from your employer plans or other sources. The social worker can help you sort out your benefits. A social worker is available on request from yourself, your family or your health care team.

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Part 3: When you go home …

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What is CCAC? CCAC stands for Community Care Access Centre. CCAC is a program, which arranges nursing, physiotherapy, nutrition and social services when you go home, if needed. Other needs which the program provides include: • drugs, dressings and medical supplies • hospital and sick room equipment

The CCAC case manager will go over your needs with you so appropriate services can be provided once you are home. If you are not eligible for the program, the case manager can help find other sources of care. You may need to make arrangements with friends and family to help you during your recovery.

How does CCAC help? CCAC helps the healing process to continue in your own home. If you need professional care when you get home, the doctor will ask the Home Care Co-ordinator to see you. If you think you will need more help and it has not yet been mentioned, tell your nurse or doctor of your needs.

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When you go home … • Most patients are ready and eager to go home 3 to 5 days after surgery. If you go home with staples in your incision, arrangements will be made for you to go to your family doctor’s office to have them removed. • Your doctor will give you a prescription for pain pills. When you have less pain, you may prefer to take plain Tylenol. If you find that an activity gives you pain, stop and rest. Wait a few days before trying that activity again. • Some people heal more slowly than others. If you still need nursing care for your incisions or your bladder is still slow to function home care will be provided. • Your incision should be a clean, dry, and closed line. Look at your incision before you leave the hospital so that you will be able to see if there are any changes to it when you are at home. • Once home, you can continue to increase your activity level gently. Remember that your need for relaxation and rest will still be greater than normal. At first you may find activities such as climbing stairs, lifting your children or vacuuming too hard for you. If you feel tired, stop and rest. Exercise can help your recovery as well. Walking is an excellent exercise that you may enjoy. You can gradually walk farther or faster for more exercise.

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• You may have a shower to help keep your incision clean and to help it to heal. You may have a bath but for the first few weeks patients usually prefer showers. Be sure to always completely and carefully pat dry your incision after washing. • After your surgery, you may feel a little discomfort when passing urine. Be sure to drink 6 to 8 glasses of water or other clear liquids such as cranberry juice each day to help prevent problems. • You use a lot of emotional energy during a cancer diagnosis and surgery. Rest and relaxation will help your recovery. Activities you enjoy will also renew your energy and sense of well being. Relaxation techniques learned in hospital can help recovery at home too. • Many patients also strongly believe in the power of prayer. You may or may not be religious, but your spiritual beliefs can bring peace of mind as you recover.

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Follow-up visits You will be given an appointment for a follow up doctor’s visit before you leave the hospital. Regular follow up appointments are made in the Cancer Centre. You will be seen a few weeks after your surgery and your Gynecologic Oncologist will determine how often you need to be seen. These visits will vary from every month to yearly.

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When to call the doctor Call the doctor if you have: • chest pain, coughing, difficulty breathing or coughing blood • foul smelling vaginal discharge from the vagina, an increased amount of discharge or any bright red bleeding or clots from your vagina • fever higher than 38.5oC or 100.4oF • pain swelling or tenderness in your calf or thigh • dizziness for more than a few seconds or fainting • burning or bleeding when you pass urine, or passing urine often • change in bowel habits • concerns about your incisions such as: • swelling, hardness or leaking • redness, bleeding or drainage • pain, which does not get better with pain pills

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Phone numbers Call this number first – Office

905-389-5688

Juravinski Hospital

905-389-4411

Juravinski Cancer Centre

905-387-9495

Doctor: ________________________________ Nurse: _________________________________ Follow-up appointment: ___________________

Questions to ask at my follow-up visit: _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________

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© Hamilton Health Sciences, 2006 PD 5328 - 05/2010 dt/May 12, 2010 WPC\PtEd\LrgBk\TotalAbdomHysterBilateralSalpingo-th.doc