What to expect after major bowel surgery
Bowel resection is a major operation from which it will take several weeks to recover, even when
everything goes smoothly. You can expect to spend 7-8 days in hospital (slightly less on average if
the procedure is done laparoscopically) and 7-8 weeks before you feel back to normal (4-5 weeks
after laparoscopic bowel surgery.
Immediate post operative care
After the operation you will be sent to a recovery area, where specially trained nurses will help you
wake up from your anaesthetic and get your pain under control. They will constantly check your vital
signs to make sure that you are stable after the operation and ready to move to the ward areas.
Most patients spend between 1 and 2 hours in recovery after major bowel surgery.
You will wake up with a number of tubes and attachments. Almost all patients will have the
following;
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A plastic cannula in your arm (Intravenous or IV line) – to give IV fluids whilst you are fasting
and for IV medications such as pain killers and drugs to control nausea.
A tube in your bladder (indwelling catheter or IDC) – To allow you to stay in bed for the first
few hours and to monitor how much urine you are producing. Urine output is the most
accurate way of monitoring a patient’s level of hydration.
A heart monitor (electrocardiogram or ECG) – to monitor heart rate and rhythm. This may
come off when you arrive at the ward if everything is stable.
A blood pressure monitor - This may also come off on the ward if there are no concerns in
recovery
An oxygen saturation clip – This clip sits on your finger and measures the level of oxygen in
your red blood cells.
An oxygen mask – to give increased levels of oxygen to the lungs whilst you wake up from
anaesthesia.
On occasions there will need to be extra tubes or attachments, such as;
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A drain or drains – A tube attached to a suction device that will take any fluids away from
the operation site. This is most commonly used in rectal surgery as fluid is prone to collect in
the pelvis and may get infected if not removed.
A nasogastric tube (NGT) – A tube that sits in the nose, but runs down the back of the throat
into the stomach, from where it drains stomach fluid. Occasionally used immediately after
surgery, sometimes needs to be inserted later in the recovery period if there is a problem
with vomiting.
An arterial line – a more complicated and invasive monitoring device inserted into an artery
in the wrist.
A central venous line – a long plastic cannula inserted in the neck to more closely monitor
hydration levels in less stable patients
From the Recovery Area you will be transferred to a ward. Many hospitals and surgeons utilise a
High Dependency Ward for the first 48 hours after major surgery, especially with elderly patients
and those with other medical problems.
In hospital care
Vital signs – Throughout your hospital stay, a nurse will intermittently monitor you vital signs. This
includes an assessment of your pulse rate, blood pressure, breathing rate, temperature and oxygen
saturation levels. Assessment will also be made of the amount of urine you are producing, the
amount of fluid coming out into any drains, your pain levels, and, if you have an ileostomy bag, the
amount of bowel fluid coming into the bag.
Blood tests – Blood tests will be taken on several occasions during your hospital stay, particularly in
the first three post-operative days and later in your admission if your surgeon thinks that it is
necessary.
Pain relief - Most patients need intravenous pain relief for a couple of days after major bowel
surgery. The most commonly used device is called a “patient controlled analgesia” device or PCA,
which consists of a syringe filled with pain relief (usually morphine or fentanyl) attach to a pump.
The patient presses a button on a hand held device and a measured dose of the drug is pumped into
the vein. There is then a lock out period when further presses of the button will not work – this
protects against over dosage. It is important that the patient is the ONLY person that presses the
button. Intravenous paracetamol (Panadol) is often also used during this time, to decrease the
reliance on the PCA.
An epidural (pain relief through a tube into the spine) is still occasionally used for pain relief in the
first few days after an operation, but is utilised much less these days than it was 10 years ago. It is
mainly indicated for patients with pre-existing lung disease or in obese patients needing a long
midline cut.
Once the gut begins to work, your surgeon will switch your pain relief over to oral medications,
including regular paracetamol and other medications, such as oxycodone (Endone) on an as required
basis.
Bowel Function – Your bowel may not work for several days after your surgery. This is quite normal.
The doctors and nurses may listen to your abdomen with a stethoscope for sounds that indicate that
the bowel is starting to work, but the first definite sign of bowel function is the passage of wind
(flatus) through the bottom or into a colostomy or ileostomy bag. About a day after you first pass
wind, a bowel action will follow. This bowel action is often liquid and may require a bit of a rush to
the toilet!
Diet – You will need to fast (that is, have nothing at all to eat or drink) when you first come back
from surgery. Your surgeon will judge when it is safe for you to start oral intake – he or she will take
into account factors such as passage of wind, bowel sounds and the absence of nausea, vomiting or
hiccups.
The usual pathway back to full diet is through a number of stages, starting with clear fluids (usually
broth, jelly, water and tea or coffee), then to nourishing fluids, then a solid but light diet and finally
up to a full diet. Recently, surgeons have established that many patients can be fed at a faster rate
than has been traditionally accepted after bowel surgery. If your surgeon thinks that you may be
suitable for this process, you may be placed on a so-called “Fast track” program.
In about 1 in 10 patients the bowel does not get started as quickly as we would like and leads to
vomiting in the post-operative period. This situation is called a paralytic ileus. Occasionally it is due
to a major complication, such as a leak from the bowel join, but more commonly it is simply that the
bowel is slow in returning to normal function. A nasogastric tube will need to be inserted if the
vomiting does not settle with medication and the IV fluids will need to be continued to maintain
hydration. If the ileus continues for over a week after the surgery, and certainly by 10 days, nutrition
may need to be given intravenously (called TPN or total parenteral nutrition).
Prevention of leg blood clots (Deep venous thrombosis or DVT) – All major bowel surgery represents
a risk period for DVT. This is particularly the case when the surgery is in the pelvis (ie rectal surgery),
when the surgery is for cancer and when the patient is obese. A number of strategies are
undertaken to reduce the risk of DVT in the post-operative period.
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Medication – You will be injected with a blood thinning medication (called Heparin or
Clexane) once or twice a day for your whole hospital stay, or at least until you are fully
mobile
TED Stockings – Specially designed stockings will be placed on your legs before surgery and
should stay on for the whole of your hospital stay. Even at home, you should wear the
stockings as much as you can, because the risk of DVT is still present for up to 6 weeks after
the surgery.
Calf squeezing devices (called sequential compression devices or SCD) – These devices are
placed on the legs at the start of your operation and will stay on for up to 48 hours. They are
attached to a machine that causes them to squeeze your calves every 30 seconds or so.
Mobilisation – getting out of bed and mobilising early in the recovery period is a great way
to decrease the risk of DVT and will be encouraged by your nurses and the physiotherapist
Mobilisation – Early mobilisation will be encouraged at all times, starting with sitting out of bed on
the first post-operative day. You will be helped by the nurses and the hospital physiotherapist to get
moving as quickly as is possible. Early mobilisation has been shown to decrease lung complications
after surgery, to decrease the risk of clots in the legs, to increase the feeling of satisfaction with
post-operative progress and to allow earlier discharge from hospital.
A positive attitude and motivation towards mobilisation, particularly in hospital but also once you
are home, is the single most important thing that you, as a patient, can do towards a successful and
swift recovery from major bowel surgery.
Wound care – Your wound (or wounds) will be assessed by your surgeon and nurses each day. The
dressings will be changed if required. If staples have been used to hold the skin together, they will be
removed between 7th and 10th post-operative day. This may need to happen after you have left
hospital.
Stoma care – Patients having bowel surgery will sometimes need a stoma, where the bowel is
brought onto the surface of the abdomen and the bowel actions go into a bag. This can be a
colostomy – usually on the left side, is made of large bowel (colon) and produces a formed stool, or
an ileostomy – which is usually on the right side, is made of a loop of small bowel (ileum) and
produces a liquid stool into the bag. A specially trained nurse, known as a stomal therapist, will help
you learn how to manage your stoma. Extensive information about stomal care and stomal therapy
is located elsewhere on the website
Discharge from hospital – You will be deemed ready to leave hospital based on a number of factors
rather than on a set post-operative day. Those factors include;
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All drips, drains and catheters have been safely removed
Your vital signs have been stable for several days, in particular that there has been no
elevated temperature
Your pain is adequately managed with tablets
You have passed urine since the catheter was removed
You are eating and drinking adequately
Your bowels are working or you are safely managing your stoma
When you leave hospital, you should have some samples of pain relief and any other medications
that were started in hospital, a follow up appointment with your surgeon and contact details for the
surgeon and the hospital in case of an emergency.
Some patients may not be able to go straight home after surgery and will require some
convalescence or even rehabilitation. There is a team of nurses at the hospital to assess this
situation and set up a transfer to another facility for this convalescence when required. If you or
your family think that this option may be needed, particularly for elderly patients living alone, it
should be discussed with your surgeon and the hospital staff early in the recovery period.
Once you are home
Expect to need to take things easy for a few weeks after your surgery. The exact time that it will take
for each step of the recovery will vary from patient to patient.
Diet – There are no strict rules around post op diet once you have gone home. The most important
message is to keep yourself hydrated by drinking enough water, at least 2 litres per day. Most
people prefer to keep their diet fairly bland, avoiding spicy, rich and fatty foods. One thing worth
mentioning is that adhesions inside the tummy are quite ‘sticky’ which means that the bowel cannot
expand very well. For the first 6 weeks after surgery it is best to avoid foods that create a bolus in
the bowel, such as nuts and hard raw vegetables (eg carrot, celery, radish). It is also more important
than ever to chew food well before swallowing.
Pain relief - Don’t let pain stop your recovery. Regular paracetamol will help you to mobilise and
sleep, both important components of getting back to normal. If pain breaks through the paracetamol
then it is important to take the stronger pain relief tablets that have been provided. If this is not
enough, please phone your surgeon to discuss the situation.
Mobilisation – Walking is essential to a smooth recovery and should be a part of each day’s activities
in the recovery period. More vigorous exercise may not be sensible, however. Whilst it is vital to
keep moving, it is equally important not to push things too far too soon. A good rule of thumb is “if it
hurts, don’t do it”
Lifting – By the time you leave hospital most of the healing inside the abdomen has occurred, and
breakdown of the bowel join is very rare. Your abdominal wound, however, is still very fragile and
can breakdown and form a hernia if it is placed under too much stress too soon. This means that
anything that increases the intra-abdominal pressure must be avoided for at least 8 weeks after
surgery.
Avoiding lifting anything even remotely heavy is essential for the 2 months after the operation. Five
kg should be the limit in this time period, about the weight of a kitchen chair.
Bowel function – Your bowels will not work normally after the operation and will always take a few
weeks to settle down. Exactly how they will work is quite variable. If a lot of bowel has been
removed, the bowel actions will be loose; if a lot of strong pain relief has been required then you
may become constipated.
People who have had rectal surgery, and particularly if pre-operative radiotherapy has been
required, will never have the same bowel function as they did before the operation. They will tend
to pass smaller stools more often and with greater urgency. They also often need to go to the toilet
several times in a row to release a full bowel action, a situation called ‘clustering’. These symptoms
do settle down slowly over time, and may continue to improve for over 2 years.
Work – The best time to return to work is quite variable and depends upon how smooth the
recovery has been and the nature of the work. A job that requires lifting will require more time off
than a desk job. At the very least you will need to be comfortable without strong pain relief and safe
to drive before you can return to work. This usually takes at least 3 weeks.
Driving – There are no strict rules regarding when it is safe to start driving again. At the very least,
however, you must have stopped taking any pain relief other than paracetamol. A reasonable rule of
thumb is to wait 3 weeks after the operation before starting to drive again. It may be helpful to take
a passenger the first time you drive, and only go a short distance. If you don’t feel comfortable, then
you can pull over and swap seats. If you have no trouble, then it should be okay for you to go out on
your own the next time.
Late complications
Wound problems – Your wound should stay dry and intact for the whole of the recovery
period. If wound pain increases, if it becomes warm or pink, or if fluid starts coming out of a part of
the wound then this is not normal and should be reported to your surgeon.
Urinary tract infection – Because you had a catheter in the bladder for a period of time
during and after surgery, there is a risk of urinary tract infection (UTI). The symptoms of a UTI are
increased frequency of going to the toilet to pass urine, burning and stinging when the urine is
passed, a fever and generally feeling unwell. You should report these symptoms to you surgeon.
Deep venous thrombosis (DVT) – DVT is a rare but serious complication of major bowel
surgery. If you have pain and/or swelling in a calf muscle in the first few weeks after an operation,
this needs to be reported and investigated. Sudden onset of chest pain or difficulty breathing may
mean that a leg clot has broken off and gone to your lungs, an even rarer complication called a
pulmonary embolism. A pulmonary embolism is a medical emergency and you should call an
ambulance and get to the nearest Emergency Department.
Stoma problems – If you have a colostomy or an ileostomy, you will be visited daily by a
stomal therapist until both you and the nurse are happy that you are managing the stoma. There is a
whole section of the website devoted to stomal therapy. The most significant immediate
complication of a stoma that can cause significant problems if not detected is a high output
ileostomy. An ileostomy should put out about 800ml of effluent that is about the consistency of
toothpaste. This will mean emptying the bag 4-5 times in 24 hours. If the output becomes much
greater than this and of watery consistency the situation can become dangerous. In the first instance
it is reasonable to simply drink more, but if the high output continues (and especially if you feel
unwell, lightheaded when you stand up and you notice your urine is less and darker) then you neeed
to be back in hospital for intravenous fluids. If this situation is allowed to continue for too long, it can
lead to kidney failure.
The above is a general summary of an average recovery from major bowel surgery. As expected
though, every recovery will be different and some people will have more trouble with some aspects
of the recovery than others. If you are worried at any time be sure to call the nurse at Colorectal
Surgery to discuss your concerns if it occurs during office hours. If she cannot answer your questions,
she will contact your surgeon for further advice. If the problem occurs after hours, then please
contact your surgeon via the paging number available on the business card or announced on the
after-hours telephone message at the rooms. If the problem seems serious and you are unable to
contact anyone (which will occasionally occur if your surgeon is operating when you ring), do not
hesitate to present to an Emergency Department for initial care. The doctors at the Emergency
Department will contact your surgeon once you have been stabilised and assessed.