The Weeks and Days Before Your Surgery
When scheduling your procedure with your surgeon, make sure you obtain an estimate of how long you will be in the hospital (usually three days). Make sure to plan accordingly, considering work schedules, holidays, and upcoming family plans.
- Clearance: You will be referred by your surgeon to an internal medicine specialist for a medical evaluation and clearance for surgery. If your own internist is on the staff at Hospital for Special Surgery and is available to see you after surgery, then your internist can provide this clearance. This typically includes a history and physical examination, laboratory tests, a chest x-ray, and an electrocardiogram. If your particular medical condition requires it, other tests might be needed before surgery, such as a cardiac stress test.
- Medications: You may be instructed by your surgeon and/or primary doctor to stop certain medications (such as strong blood thinners like Plavix or Coumadin) several days to a week before your surgery, depending on the medication. A new medication might be added for you to take until the time of surgery, depending on your medical history. In addition, you may be instructed to take some of your medications the morning of surgery even though you won't be able to eat that morning. It is important for you to bring a list (or a bag of pill bottles) including all your medications to your medical clearance, including vitamins, over-the-counter medications, and supplements (a number of medications and supplements may interact with medications you might receive after surgery).
- Preparation: During the weeks before your surgery, if safe, you will be given the option of donating blood for yourself. Some patients recovering from hip surgery receive at least one transfusion, and this enables you to receive your own blood.
The day before your scheduled procedure, a nurse from HSS will call you with additional instructions and reminders. You will be told when and where to come the next morning, and you will be reminded not to eat or drink anything after midnight. This does not apply to the medications that you have been instructed to take the morning of surgery with a small sip of water.
The Morning of Surgery
On the morning of your surgery, you will arrive several hours before your procedure is scheduled to begin.
- The “Holding Area”: You will come to the preoperative “Holding Area”, where you will be prepared for surgery. Patient belongings are stored until after the surgery, but please leave any valuables at home. This includes all jewelry, as you will be asked to remove everything before entering the operating room. You will be asked to change into a hospital gown, and will be assigned a bed in the holding area. Your family can be with you during this time. A nurse will start an intravenous line to give you fluids, and if you are a woman of child-bearing age, you will be asked to provide a urine specimen for a pregnancy test.
- Preoperative Exam: A physician’s assistant will take your history and perform a physical exam. The main purpose of this examination is to see if anything has changed since you last saw your medical or surgical physicians. You will be asked to confirm what type of surgery you are having and will be asked to sign consent for that surgery if you have not already done so. Your surgeon will come to speak to you and sign your surgical site. This is simply a safeguard to confirm where on your body the surgery will be performed. At this time, you will also meet your anesthesiologist and discuss what type of anesthesia you will receive.
Hip surgery can be performed under two major types of anesthesia. These two types are general and regional anesthesia.
- More than 90% of the hip surgeries at HSS are performed under regional anesthesia. The regional technique used for hip surgery is combined spinal-epidural anesthesia. You will be comfortably sedated before the spinal or epidural and will remain sleepy for the surgery. Spinals and epidurals involve the injection of local anesthetic in the lower back that will numb the nerves from your waist down.
After this injection, a small plastic catheter will be placed at the site so that more local anesthetic can be infused after the surgery to control the pain. When you wake up after surgery, your legs will be numb. This will resolve over the first few hours after surgery.
Regional anesthesia, as it is practiced at HSS, has also been shown to reduce blood loss and post-operative complications such as blood clots in the legs and lungs. Additionally, when you receive this type of anesthesia, you will feel no pain during the surgery. As a result, you will need to receive less sedative and pain medication, which makes your recovery faster and more comfortable with fewer side effects such as sleepiness and nausea.
- Another regional anesthesia technique called a lumbar plexus block may be given to help decrease the pain after the surgery. This includes a different injection in the back, while you are sedated, to numb the nerves going to the hip.
- General anesthesia involves being put to sleep with medications that are given through your intravenous line. Once you are completely asleep, a breathing tube is placed into your lungs and your anesthesiologist will assist your breathing with a ventilator. You remain completely asleep and comfortable until the surgery is complete, at which time you will start breathing on your own, the tube in your lungs will be removed, and you will awaken comfortably in the operating room.
Usually the surgeon will request that the blood pressure be kept low during the surgery in order to decrease blood loss, improve visualization, decrease operating time, and even improve prosthesis fixation. We accomplish this through a specialized technique, known as controlled hypotension, which employs specialized monitoring, epidural anesthesia, and drug infusions to support your cardiovascular system.
The Operating and Recovery Rooms
- Anesthesia/Surgery: After your consultation with the anesthesiologist, you will be taken to the operating room by a nurse. Once there, your anesthesiologist will check your blood pressure and EKG and will start giving you sedative medication. One of the forms of anesthesia discussed above will be administered. Your anesthesiologist will place one or more IV's in your wrist and/or neck to monitor your heart and blood pressure. You will remain sedated during these procedures. At this time, the surgery will begin. You will be asleep during the procedure, and when it is complete your surgeon will speak with your family and you will be taken to the recovery room.
- Recovery: In the recovery room, you will fully awaken from the sedation. Your doctor or someone from his/her team will come by and speak with you about the surgery. Your pain will be controlled with a constant infusion of medication through the epidural catheter in your back. In addition to this infusion, you will be given a button to push when you need extra pain medicine through the catheter. This is called PCA, or patient-controlled analgesia.
Recovering in the Hospital
- Physical Therapy: The recovery process will be an active one. You will likely begin working with a physical therapist the day of your surgery. This is an important part of your recovery that will allow you to get back to your normal activities as soon as possible.
- Pain Management:An anesthesiologist and a nurse from the anesthesia Acute Pain Service will visit you to evaluate and treat your pain. On the first day after the surgery, you will begin to take oral medications as the medicine through your epidural catheter is slowly decreased. By the day after surgery, you will have completed the transition to oral pain medications and the epidural catheter will be removed.
After two to three days of recovery, you will be discharged home with a prescription for pain medication, a prescription for physical therapy, and a follow-up appointment with your surgeon.
Reviewed and updated by Devan D. Bhagat, MD
12/5/2011 Reviewed and updated by Shawna Dorman, MD