Advice for Patients having Thoracic Surgery

A Thoracotomy is the name given to the incision on the chest, which allows the surgeon to gain access and look directly at the lung. The incision extends from mid shoulder blade, following a rib line to under the armpit.

The surgeon can then assess how much of the lung will need to be removed. A Lobectomy (part of the lung) a Pneumonectomy (the whole lung).

The preparation – you will be seen in a pre-admission clinic for routine tests such as Chest X-ray, E.C.G. (heart tracing) and blood tests around a week before your surgery.

The length of time you will be in hospital depends upon your condition and your surgeon will give you guidance on this. When the Consultant saw you in the clinic and advised the operation, they would have advised you to stop smoking. This is very important as your recovery could be prolonged if you continue to smoke. Use this opportunity to give up smoking completely. It may help to contact the NHS Quitline.

The surgeon or one of the team will explain the operation to you and you will then be asked to sign a consent form. You must be satisfied with the details given and understand them fully, before signing the consent form, this is to ensure that you understand the operation and its possible complications. If you have any queries please do not hesitate to ask the doctor or nurse.

Risks, side effects and possible complications

With any surgical procedure there are certain risks attached. The surgeon will discuss the risks with you. Although we appreciate this may be worrying to read not all patients will experience side effects but we do need to make you aware of them.

Sore throat

It is normal to have a sore throat from being anaesthetised, this should settle in a few days.

Damage to teeth

Teeth can occasionally be damaged from the anaesthetic and broncoscopy instruments. All the staff will try very hard to prevent this. Please ensure you let the doctors know if you have any loose teeth, caps or crowns.

Coughing up blood

It is normal to cough up a little blood for the first few days after lung surgery. The nurses and physiotherapists will help with breathing exercises after your surgery to clear this. It will gradually get less over time.

Chest Infections

This occurs in about 5% of patients having thoracic surgery. Physiotherapy, early mobilisation and adequate pain relief can help reduce this risk. If you do develop a chest infection you may need treatment with antibiotics which may result in you staying in hospital for a few extra days.

Pain

It is normal to have pain after this operation. Regular pain relief will be given to control the pain and it should settle in a few weeks. Very occasionally pain does not settle. If this is the case you may need to see a Specialist at a pain clinic.

Bleeding

Following lung surgery some blood loss into your chest drains is normal. A small percentage of patients having a thoracotomy will need to return to theatre to control the bleeding.

Wound infection

Showering in an antiseptic solution before your surgery, frequent hand washing and using the alcohol rubs provided helps to prevent this risk. A small percentage of people having this surgery will develop a wound infection requiring antibiotics and wound dressings. This may involve district nurse input following your discharge.

Empyema

This occurs rarely and is an infection between the lung and the chest wall and will require longer term drainage.

Blood Clots

These can occur in the legs and then travel to the lungs. The risk is greatly reduced by wearing support stockings, Flowtron boots, having daily injections of a blood thinning drug and early mobilisation.

Faster heartbeat

This can occur following lung surgery and may be treated with drugs to slow the heart rate down.

Air leak

This is when the cut surface of the lung leaks air and is a frequent occurrence following lung surgery. It usually settles within a few days but will mean that the chest drain has to stay in your chest until this happens. If it is taking longer to resolve you may be discharged home with a drain in, and to come back to the ward weekly for review

Pneumothorax

Occasionally the remaining lung will not fully inflate following your surgery and so may mean having the drain for longer. Sometimes once the drain is removed your lung may partially collapse. This will either resolve itself or occasionally require a new drain to be inserted

Heart attack or stroke

This can occur during or after surgery. The risk is higher in patients with a cardiac history or undiagnosed cardiac disease. For this reason you may require to have extra investigations and a full assessment prior to your surgery.

Disorientation

Some patients whist recovering from surgery might be disorientated with the ward and the people around them. They may behave differently than normal and temporarily have loss of memory. This is often a reaction to the anaesthetic drugs and the strong pain relief you are given

Risk of death

Any surgery carries a degree of risk and this can include a risk of death. The risk will vary for each patient. Your surgeon will discuss specific risks that apply to you. Please remember you can ask any questions and voice any concerns at any time to the doctors and nurses looking after you.

Changes in blood pressure

Sometimes your blood pressure may be lower after an anaesthetic. This is normally due to not having enough to drink for a while. You will be asked to drink more or you may need to have fluids through a tube into a vein in your arm.

If it is decided you have to come in on the day before your surgery you will be phoned about 1pm that day and asked to come in at a specific time to either ward 38, 39 or the Lancashire suite who will then continue your treatment as above.

The Nursing Staff will tell you when you have to stop eating, prior to the surgery but you can drink plain water up until your surgery. You will be advised by the Nursing Staff when to put your theatre gown on and remain on your bed and you may be given a pre-med; when it is time to go to Theatre your details will be checked and you will be escorted there by a Nurse and a Porter.

The nurse escorting you will hand over your care to the theatre nurse after checking your details. You will then be taken into an anti-room where the anaesthetist will administer your anaesthetic and from this point you will be aware of nothing until the operation is over.

After the operation the anaesthetist will wake you up and you will be placed back in your bed. When the anaesthetist is satisfied with your condition they will give permission for you to be transferred back to the ward or intensive care unit. On transfer back you will have one or more drains in place, which are attached to drainage bottles. Your wound will be covered with a padded dressing.

You may have a urinary catheter in place so we can observe your urine output. You will have an oxygen mask in place and will be required to wear this continuously over night.

Whilst you are not eating or drinking, an infusion of clear fluids or blood will be in progress through a small needle in the back of the hand.

You will probably be very drowsy and because of having a general anaesthetic you cannot eat or drink for about 4 hours after surgery. After this period you will be given a drink.

During the first few hours your nurse will keep a close check on your recovery by taking your blood pressure, pulse, temperature, respiration rate and oxygen saturations. Also observing your wound and recording drainage from your drains and assessing your pain to ensure you are kept as comfortable as possible. They will also ensure you have passed urine. Most patients are nursed in a semi-sitting position supported by pillows.

At Blackpool teaching hospitals NHS foundation trust we aim to provide high standards of care based on current recommendations and protocols. E.R.A.S is part of this.

The E.R.A.S programme provides daily goals to achieve. Please remember that these goals are set to be worked towards, but everyone is an individual and will achieve these goals at different times.

The following morning you can have a light breakfast. The doctor will come to see you and review your progress on a daily basis. They may request that you have a chest x-ray and some blood tests. The x-ray is carried out on the ward at your bedside.

Your nurse will assist you to have a wash and they will then sit you in a chair for a short period if your condition allows. If you are following E.R.A.S. you will already been in your chair at the day of surgery.

The physiotherapist will come and see you and ask you to do some deep breathing exercises, coughing, leg and arm exercises. It is very important that after thoracic surgery you keep your chest clear by coughing regularly. Remember you cannot upset the operation by coughing vigorously.

Early mobilisation is important as it prevents complications. On the first day after surgery you will be sat out in a chair. You will be encouraged to stand regularly with the nursing or physiotherapy staff.

As your condition improves you will gradually be assisted back to full mobility and independence by the time you are ready for discharge. You may if you wish wear your own clothes i.e. tracksuit or loose fitted shirt  and shorts or skirt.

Your Consultant will assess your condition and when they are satisfied with your recovery they will give you a proposed date for discharge. During your recovery, together with your nurse and your family, you will be able to plan for your discharge. We ask that someone collects you on the day of discharge.

The nurse discharging you will give you a seven-day supply of medication, which has been prescribed for you by the doctor. They will explain the medication, dosage, frequency and continued administration. You will also be given a letter for delivery to your GP. This letter tells the GP about your operation, medication and that you have returned home and will now be under their care again. Advice about any appointments you need to attend will be given to you.

Discharge Date

Most patients are considered ready for discharge 4-7 days after surgery, provided chest drains are removed and that you are well enough to be discharged. Some patients have to keep their drains in for longer if there is still some air leaking from the area of the lung operated on. On occasions patients are discharged home with a drain in which allows them to be fully independent and mobile. In these circumstances you will be asked to come back to the ward for regular checks whilst the drain is in place to see the Thoracic Specialist nurse who will remove your drain when the leak subsides and your lung is fully inflated

It is normal to have good days and bad days. The good days are to remind you that you can feel normal again. If you do too much on a good day you may have a couple of bad days, learn to pace yourself remember little and often.

You may require a sick note for your stay in hospital so please remember to ask the Nursing Staff to arrange this for you so that is ready for you when it is time for you to be discharged from the Ward.

Exercises and Activities

Following surgery you should be gradually increasing your activities. Walking is the best form of exercise. The first walk at home should be that of a similar distance that you have been doing in hospital. Use your discretion at building up your distance each day; remember you have to walk back. Wrap up comfortably if the weather is cold. Gradually increase your distance of walking to 2 to 3 miles by your clinic appointment. Most important to remember that we are all individuals, some people may be doing more or less than others.

Dos and Don’ts

Whilst awaiting your clinic appointment (approximately 6 to 8 weeks after surgery) no digging the garden, no mowing the lawn, no heavy lifting e.g. the grandchildren, no shifting snow, no cleaning windows/baths, no driving.

Bathing and Showering

The nurses on the ward will advise you of when to take a shower or bath. Before this can happen your wound needs to be healing well with no oozing of fluid from the wound. All drips and drains need to have been removed before you can shower or bathe. This usually occurs around the 4th day after your operation.

Some general points to note are outlined below:

• Showering is preferable to bathing.

• All dressings need to be removed before having a bath or shower.

• Don’t use any soap, shower gel, body lotion, talcum powder or other bathing products directly over the healing wound.

• It’s alright to allow the shower water to gently splash onto the healing wound. However don’t rub the area, as this will cause pain and might delay the healing process.

• Only have a bath if the healing wound can be kept out of the water.

• Don’t soak the area as this might soften the scar tissue and reopen the wound.

• Dry the healing area carefully by patting it gently with a clean towel.

Surgical site infections compose of up to 20% of all infections that patients acquire while they are in hospital. At least 5% of patients who undergo surgery develop an infection in the surgical wound.

The majority of these infections are preventable and measures are taken by hospital staff before, during and after the operation to reduce the risk of infection. One of these measures is to give intravenous antibiotics before, during and after the operation. The use of these precautionary (prophylactic), antibiotics has been shown to reduce the risk of infection following surgery.

There are a number of things that you can do to look after your wound, lower the chance of infection and encourage healing.

Dressings

The purpose of a dressing is to:

• Absorb any leakage from the wound

• Provide ideal conditions for healing

• Protect the area until the wound is healed

• Prevent stitches or clips catching on clothing

All dressings are removed after 3 days providing that the wound is dry and not soaked with blood or any other liquid. Once the dressing is removed it is important that you do not touch the healing wound with your fingers. The healing wound can then usually be left without a dressing. Some people like to continue wearing a dressing over the area for protection, especially if clothing is going to rub against it. If this is the case, apply the dressing carefully and don’t touch the inside of the dressing. There is no need to use antiseptic cream under the dressing

Problems With Wound Healing

Most surgical wounds heal without causing any problems. However, wound infections are one of the most common complications after surgery. This means that germs have started to grow in the wound and this can delay normal healing. Wound infections are usually treated with a course of antibiotics, but occasionally further surgery is needed.

A surgical wound is the cut made in the skin by your doctor during an operation. At the end of the operation, most cuts are stitched to allow the skin edges to come together and heal. The skin edges usually form a seal within a day or two of the operation. This time varies from person to person and from operation to operation. Certain people are more likely to develop wound infections and your Doctor will discuss this with you.

Those at higher risk include people who:

• Smoke

• Have diabetes

• Have a condition or treatment that affects their immune system, such as leukaemia or chemotherapy

The surgical wound that has been made on your side to do your operation is called a thoracotomy. The area around the wound may feel numb; the sensation may or may not come back.

Your Doctors and Nurses will do everything that they can to prevent your wound from becoming infected while you are in hospital, but it is important that you know how to tell if you are developing an infection after you go home.

If a wound becomes infected, it may:

• Become more painful

• Look red, inflamed or swollen

• Leak or weep liquid, pus or blood

• Smell unpleasant

Check your wound daily, either in the mirror or allow a member of your family to check. If it is red and inflamed contact your GP or Ward 38 or 39.

Stitches

The medical term for stitches is sutures. Some stitches are dissolvable and don’t need to be removed. Other types of stitches have to be removed by a nurse or doctor. Wound stitches are self-dissolving, you will only need the drain sutures removed prior to discharge or the nursing staff will advise you to go to your local medical centre to have them removed.

Taking Care of Stitches

Dissolvable stitches will usually disappear on their own in 7 to 10 days. Non-dissolvable stitches may not be removed for up to two weeks. You may see small pieces of the stitch material poking out of the healing wound, which has dissolvable stitches. Don’t be tempted to pull on these. Wait until they fall out on their own. If the stitches cause you pain or discomfort, contact ward 38, 39 or your GP for advice. If after going home your wounds become red or inflamed and begin to weep contact LS, ward 38, 39 or your GP. As long as your wound is healthy and closed, it is preferable that you have a bath or shower each day. This will help with healing of your wounds.

Posture and Exercise

Look in the mirror to check your posture. There is often a tendency to lean towards the operation side. It is important to keep muscles and joints mobile during the healing process. Exercises start the day after surgery. These are a few general exercises to help prevent stiff shoulders, neck and back. They should be done gently, twice a day. Do each exercise 3 times. Start by slumping in your chair so your whole spine is bent forward, then sit up making your spine straight and take your shoulders back. Now you are in the correct position to start the exercises.

Start by slumping in your chair so your whole spine is bent forward, then sit up making your spine straight and take your shoulders back. Now you are in the correct position to start the exercises.

1. Turn your head slowly to look over your right shoulder, hold at the end of the movement for a few seconds, then turn to look over your left shoulder and hold for a few seconds.

2. Look straight ahead, take your chin down your chest, and then lift your head to look up at the ceiling.

3. Look straight ahead, take your right ear down to your right shoulder, and then take your left ear down to your left shoulder.

4. Lift your arm above your head, stretching up as high as you can leading with your thumb (this may be limited in the early days after surgery, but should return to normal).

5. Place your hand on your shoulder; take your elbow out to the side away from your body until level with your shoulder. Circle forwards 3 times and backwards 3 times.

Breathing Exercises

1.Your Physiotherapist will advise you if it is necessary to continue with these on discharge.

2.Check your sputum production – if this is increasing in quantity or changing in colour you may have a chest infection, so contact your own GP for advice or ring ward 38 (01253 957738) or ward 39 (01253 957746).

3.Do not smoke and avoid smoky atmospheres.

Discharge Home with a Chest Drain into a Drainage Bag

If you do need to be discharged with a chest drain in place, a district nurse will be arranged to come to your home and undertake the care and management of the drain and bag. If at any time the drain should accidentally fall out, contact your GP, ward 38 or ward 39 for advice. Drainage bags/dressings will be provided on discharge.

Sleep and Rest

It is common for patients following surgery, whilst in hospital and on discharge to feel extremely tired. This is normal and should be the limiting factor to your progress. Try a nap in the afternoon as you did on the ward for an hour or two or retire to bed early in the evening.

Pain

Try and have paracetamol at home. Don’t hesitate to take stronger painkillers, which can be obtained from your GP (unless these have been prescribed on discharge). Take painkillers if you need them for pain, discomfort or even soreness. Don’t be a martyr and try to put up with pain. It will make you miserable and may stop you from doing your deep breathing exercises efficiently. If the pain persists contact your GP or ring ward 38 or 39 for advice.

Driving and Activities

Ask your Consultant about when you can commence driving, otherwise – you must not drive for 6 to 8 weeks after surgery until you have been seen for your clinic appointment.

You do not qualify either as a driver or a passenger for a seat belt exemption, so seat belts should be worn. Six weeks after surgery you can usually start swimming or riding a bike (following your outpatient clinic check).

Three months after the operation you can play golf again, maybe start at the driving range and then progress to eighteen holes.

Build all activities up gradually keep active and establish a regular exercise routine.

Stockings

From discharge they should be worn for 4 weeks in total. For 2 weeks all the time apart from bathing and changing them. For the last two weeks you may wear them during the day only e.g. take them off at night, then put them on in the morning. Or take them off for sunbathing and put them on after

Smoking

Don’t smoke and avoid smoky atmospheres. Contact Better health website.

Alcohol

Excess alcohol consumption should be avoided, more so if you are taking painkillers, use your discretion.

Diet/Constipation

To prevent constipation eat a high fibre diet with plenty of fruit, bran and vegetables. If you are constipated contact your GP or ask your local pharmacy for medication to assist. Ensure you drink plenty of fluids. Painkillers can be the cause of constipation.

Emotions

Every day you may feel different emotionally. You may run on a short fuse, this is a normal reaction but it does help if you can talk to someone about how you are feeling. Although you have had to endure all the pain and surgery it is important not to forget about those at home who may also be feeling lonely or frightened that they have been on their own whilst you have been in hospital. They too need to have a break from the day instead of pushing themselves too far.

Sex

You may resume your normal sexual activity when you feel fit. There is no need to restrict these activities as you continue towards your normal physical health.

Holidays

As a general rule most people are able to enjoy a holiday either abroad or in this country approximately 10 to 12 weeks after surgery. Under normal circumstances you should be able to fly by then.

Return to Work

This depends on the type of work you do. It is usually 2-3 months after the date of the operation or maybe sooner if your Consultant allows you. Most people should be able to return to their previous occupation. Return to manual work maybe longer than a desk job (if you require a sick note ask the nursing staff for one)

You will be sent an appointment through the post approximately 6 to 8 weeks after discharge for a postoperative check. You will also be contacted during your first week at home by the Thoracic Specialist nurse. If you have any problems or worries before this call she can be contacted on 01253 300000 and ask for bleep 1285 or 2030 or leave a message on 01253 957718.