PREOPERATIVE INSTRUCTIONS
You will have an appointment in advance of surgery to go through the details of your surgical day with you. However, reading about some of these instructions in advance may prepare you for what to expect. Certainly, if there is a discrepancy between these instructions and you are received instructions from preop clinic, feel free to contact the office for clarification.
Medications
Starting and stopping medications in advance of your surgery is a big part of the preoperative clinic. They will go in great detail about which medications to stop in which to continue, and if they are stopped, when they should be stopped. Particularly with respect to blood pressure medicines, pay attention to the instructions provided by your preoperative clinic visit.
Blood thinners: Medications such as Coumadin, Lovenox, Xarelto, and Eliquis need to be stopped in advance of surgery. If they are not stopped, your surgery will be canceled as it is too dangerous to operate while you are on these medications. You will have received instructions on when to stop these medications. Typically, Xarelto and Eliquis are stopped 2 to 3 days prior to surgery and held for 2 to 3 days after your surgery. Clarify exactly when these will need to be stopped with your surgeon. Coumadin is typically stopped 5 days prior to surgery. Depending on the indication for anticoagulation with Coumadin, you may need to be bridged with a medication such as Lovenox, which is typically stopped the day before surgery. If you cannot take Lovenox, you may need to be bridged with a medication called heparin which would require you to be admitted to the hospital, as this medication is administered through an IV.
GLP-1 agonists: This is a new class of medications used for diabetes and weight loss. This includes medications such as Mounjaro, Wegovy, Trulicity, Ozempic, and Victoza. New medications in this class may be emerging soon as well. These medications cause significant delay in gastric emptying which may lead to aspiration (vomiting) during intubation for general anesthesia. This is very dangerous and an unnecessary risk to you for an elective operation. If you are taking this medication, please make sure to note this during your clinic visit, surgical scheduling, as well as during your preoperative medical visit. You will need to be on clear liquids for 48 hours prior to surgery, with nothing per mouth overnight. We have found that this protocol allows for safe induction of general anesthesia and intubation.
Diabetic medications: If you take medications for diabetes regularly, you will receive instruction about which ones to continue in which to stop prior to surgery. Typically, these will be held the morning of your surgery, and any long-acting medicines may be held or decreased the night before surgery. If you are on an insulin pump, or are a type I diabetic, you will likely need to continue on your pump, but discuss an adjustment to your pump settings or an alternative medication regimen if your pump needs to be stopped with your endocrinologist.
Diet: There is no special diet to follow prior to surgery, unless you take a GLP–1 agonist. If you are taking one of these medications, you will need to be on clear liquids for 48 hours prior to surgery, and nothing per mouth from midnight prior to surgery.
Blood pressure medications: If you are taking blood pressure medications to control your blood pressure in advance of adrenal surgery, make sure you continue to take your medications up to and likely including on the morning of your operation. It is very important that you remain on these medications and follow the instructions regarding administration, as well as fluid loading in advance of surgery. In particular, this is needed for removing special tumors of the adrenal gland called pheochromocytomas. If there is any question regarding your medications, please be sure to contact your surgeon for clarification.
Smoking: I recommend abstaining from smoking at least 1 to 2 weeks prior to surgery and for 2 weeks following surgery as smoking can irritate the airways and promote coughing, which can lead to wound issues, bleeding, or formation of seromas and abdominal wall hernias. Additionally, smoking promotes constriction of microvasculature with his leads to abnormal and delayed wound healing. Also, it is just bad for you in general.
POSTOPERATIVE INSTRUCTIONS
Pain: Following surgery, you will be discharged home with pain medications. You will experience abdominal pain along the surgical incision sites, particularly the extraction site for the tumor. This will improve over time. The prescribed narcotic pain medication should provide sufficient pain relief for this type of discomfort. The addition of scheduled Tylenol or ibuprofen can oftentimes provide good adjunct nonnarcotic pain relief as well. Using a heating pad or ice pack over the incision, is well as an abdominal binder, can sometimes provide relief as well. If your surgery was through a lateral approach, you will have incisions along the front and lateral aspect of your abdomen, near the boundary of the rib cage on either the left or right side. There will be 3 incisions on the left side and 4 incisions typically on the right side. If your surgery was from a posterior approach, you have 3 incisions just below the lower boundary of the rib cage on the backside, on either the left or right side.
Medications: If you had a unilateral adrenalectomy with some suggestion of cortisol secretion, you will require a test in the morning called a cosyntropin stimulation test to determine if the remaining adrenal gland is producing enough cortisol to be safely discharged, or if you require some steroid for support. If your remaining adrenal gland does not produce enough steroid, you will be discharged home on a medication called hydrocortisone 1-2 times daily. Your surgeon will give you more details about taking this medication at the time of discharge. Typically it is taken at 8 AM, and then at around 2 PM.
Diet: There are no dietary restrictions following your surgery. You are free to eat and drink what ever you wish, although I would recommend abstaining from alcohol after your surgery as that may impair your judgment in combination with any anesthetic or pain medications that you received. For your first meal, try eating something relatively mild and easy to digest as you may experience some nausea from the anesthesia.
Driving: You may return to operating a vehicle when you are no longer taking any narcotic pain medication to help with pain relief. This is usually 1 to 2 days following surgery.
Weightbearing: Avoid heavy weightbearing following surgery as this can lead to increased venous pressure and promote bleeding in the neck. You should restrict your weightbearing to less than 10 pounds for the first 2 weeks following surgery. Avoid activities such as cycling, jogging, swimming, golfing, or jumping up and down, any activities which require exertion of the abdominal wall musculature, which can increase your pain as well as promote separation of the skin incision or development of a hernia through the abdominal wall. You can increase your weightbearing to 20 pounds from weeks 2-4, and 30 pounds from weeks 4-6. Abdominal wall strength will improve to closer to baseline by 6 to 12 months following surgery.
Water: You can resume showering per normal routine the day after surgery. Leave your dressing intact. Avoid excessive wetting of your surgical incision, although if it gets a little bit wet when washing her face or hair, that is fine. Pat the dressing to dry it, rather than rub it. Do not swim or take a bath. Do not sit in a hot tub or sauna.
Work: If your job is mostly clerical and does not require heavy weightbearing, you can oftentimes return to work about 1-2 weeks following your surgery if you desire. If you have heavy weightbearing as part of your job position, you may not return to work with any of the heavy weightbearing responsibilities. If you cannot avoid heavy weightbearing in your job, you will need to remain out of work for 4 to 6 weeks.