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. Depending on the type of surgery, you may go home the same day, or you might be admitted for up to four 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. The clearance typically includes a history and physical examination as well as laboratory tests. If your particular medical condition requires it, other tests might be needed before surgery, such as an EKG or a chest x-ray; on occasion, you might need additional testing 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. 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).
On the day before surgery, the preoperative nurse will call you to tell you what time to come in, what medications to take, and by what time you should no longer have anything to eat or drink. This does not apply to the medications that you have been instructed to take the morning of surgery with a small sip of water. Make sure you follow their recommendations strictly, otherwise your surgery may have to be re-scheduled.
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. A locker will be provided for your belongings, 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 (referred to as an ‘IV’) 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 or one of his or her assisting physicians will come to speak to you and to 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 who will discuss what type of anesthesia you will receive.
There are several techniques available to provide anesthesia of the foot. Your anesthesiologist will present you with the technique best suited for your surgery based on the exact location of the area to be operated on. The anesthetic for foot surgery typically consists of IV sedation combined with regional anesthesia. The regional anesthesia techniques may include a nerve block and/or spinal-epidural anesthesia, depending on the proposed surgical site. A spinal or epidural is an injection of local anesthetic into the lower back that will make you numb from the waist down, ensuring you don’t feel any pain during the surgery. If an epidural is used, a small catheter is placed in your back so additional local anesthetic can be injected during and after the surgery. In addition to the spinal or epidural, a nerve block (ankle, popliteal or saphenous block) may be performed. An ultrasound is used to inject local anesthetic around the appropriate nerves to help reduce the pain you experience after the surgery.
How long the nerve block lasts can vary and should be discussed with your anesthesiologist. Depending on the extent of the surgery, a catheter may be placed near the nerve to allow more local anesthetic to be injected. You will be sedated prior to the anesthetic procedures and throughout the surgery. Some foot surgeries are performed under general anesthesia alone or in combination with a nerve block. General anesthesia involves being put to sleep with medications given through your IV. Once you are completely asleep, a breathing device is placed into your mouth and your anesthesiologist will assist your breathing with a ventilator. You will remain asleep until the surgery is complete, at which time you will start breathing on your own and you will wake up completely in the operating room.
The Operating and Recovery Rooms
- Anesthesia/Surgery: You will be taken to the operating room by a nurse, where your anesthesiologist will check your blood pressure and EKG and will begin giving you sedative medication. One of the forms of anesthesia discussed above will be administered, and the surgery will begin. The level of sedation is variable, but most people remember waking up in the recovery room after the operation is completed. Occasionally, some patients recall some music or perhaps the sound of some tools being used. Be assured that you won’t feel any of the surgery. When the surgery 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 be placed back on the same monitors that were used in the operating room. If you received an epidural or spinal anesthetic, your legs will be numb. You will begin to regain some sensation after about one hour in the recovery room. If you had a nerve block, the affected area will continue to be numb for many hours. If you will be going home that same day, you will receive detailed instructions for taking care of yourself at home and a prescription for pain medication.
Depending on the complexity of your procedure, your surgical physician may admit you to the hospital. If you will be staying in the hospital for a few days, your postoperative pain will be managed with a combination of pain pills by mouth and an infusion of medication through either your IV or a catheter that you control with a button. This is called PCA, or patient controlled analgesia. The pain pump is calibrated so you cannot harm yourself, no matter how many times you press the button.
If you are discharged home on the day of your operation, you will probably still be very comfortable because of the nerve block you received. The effects of the block will start to wear off during the evening or overnight, depending on the time that the block was performed. For optimal pain control, you should begin taking the pain pills prescribed to you by your surgical physician before going to bed or as you begin to regain sensation. Be sure to take the medication with a light snack, because nausea is a common side effect of pain pills.
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 after 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 nurse from the Acute Pain Service will visit you each day to evaluate your pain. On the first day after the surgery, you will be transitioned from the PCA to oral pain medications. Once you are comfortable with the oral pain medications, the epidural catheter or peripheral catheter will be removed
After one to four days of recovery, you will be discharged home, likely with a prescription for pain medication, a prescription for physical therapy, and a follow-up appointment with your surgeon.
Reviewed and updated by Philip J. Wagner, MD