Hysterectomy--Removal of the Uterus (Womb)

December 14, 2007

Overview

There seems to be some misunderstanding about what a "complete" hysterectomy is versus an "incomplete." I have found most patients in my practice say complete when they mean not only the uterus (womb) was removed, but also both tubes and ovaries. This is incorrect. All a complete hysterectomy means is that the entire uterus was removed. There is no relation to the tubes and ovaries. It's important to get this straight, because a planned complete hysterectomy may have a patient and her doctor talking about two different operations.

For the record, a complete hysterectomy is removal of the entire uterus, including the cervix and body of the uterus. A subtotal hysterectomy leaves in the cervix (just removes the body of the uterus)--a rare operation today. (A trachelectomy is the removal of just the cervix sometime after a subtotal hysterectomy).

A hysterectomy can be an abdominal hysterectomy (abdominal incision), a total abdominal hysterectomy being called a TAH. Salpingectomy is the removal of a tube. A bilateral salpingectomy is removal of both tubes. An oophorectomy is the removal of an ovary, and bilateral oophorectomy the removal of both ovaries. Removal of the entire uterus + tubes + ovaries is a TAH-BSO (total abdominal hysterectomy/bilateral salpingo-oophorectomy).

A hysterectomy can be a vaginal hysterectomy, wherein the uterus is removed by separating all of its connections from the vagina and upper pelvic tissues from a vaginal approach. The layperson may refer to this as a "blind" hysterectomy.

A laparoscopic hysterectomy (LAVH--laparoscopically assisted vaginal hysterectomy) is nothing more than a vaginal hysterectomy wherein the top parts of the uterus are surgically separated from their attachments through a laparoscope, using staple/cutters or cautery/cutters, and then the rest is done as a vaginal operation. This is a situation wherein a surgeon might anticipate trouble removing the uterus through a straight vaginal hysterectomy. For instance, there may have been previous pelvic surgery that may have cause adhesions, sticking bowel to the uterus. (Seeing bowel come out with the uterus would be an unwelcome surprise!) A laparoscope can help you look before you leap. It can also be used to look for causes of pain, like endometriosis, before pressing on with the hysterectomy. A laparoscope can help identify those women who would not make a good vaginal hysterectomy candidate.

Indications for Hysterectomy

The uterus does two things: it bleeds and it carries babies. When the baby-carrying is over, it still bleeds. This is the way we are, and it's O.K. But some women do more than just go on with regular cycles. Irregular bleeding can be a source of not only discomfort and compromise, but also of danger. When bleeding becomes so heavy or prolonged, or when the cramping becomes so incapacitating, that a woman can no longer live a normal life, a hysterectomy is indicated. Sex is important, and if intercourse is painful because of relaxation of the ligaments that hold in the uterus, then a hysterectomy can be crucial to consortium. Athletic women may not be able to tolerate a "fallen" uterus, which not only causes back and thigh pain, but also may contribute to urinary incontinence.

Dangerous conditions as well can result from heavy or prolonged bleeding. Severe anemia and even life-threatening shock from vaginal hemorrhage can prompt an emergency hysterectomy. Taking advantage of indicated hysterectomies before they become emergency hysterectomies offers the protection of working under controlled circumstances.

Distortions of the anatomy due to uterine fibroids (leiomyomata) can threaten to impinge on other strutures and compromise their normal activity. For those who suffer the pain of recurrent endometriosis, sometimes there is no treatment left except to remove the source of the endometrium--the uterus.

In considering who to do a hysterectomy on, a gynecologist must first clear the prime consideration out of the loop--does this woman want any more pregnancies? If there's even a shadow of a doubt, if she's single, or if she has no children, then hysterectomy should be done only if not doing one is medically unacceptable. Also, does a normal pelvic exam reproduce her pain? Bleeding is subjective. A doctor cannot do an exam and determine whether a patient is or is not bleeding enough to consider or discourage a hysterectomy. We must rely on the history for that. But pain is different. Except for painful intercourse (dyspareunia), pelvic pain ought to be able to be recreated with a pelvic exam. If so, then the pelvic organ(s) are likely to be the origin of, and removal the treatment for, the pain. If the pain cannot be recreated, then orthopedic or gastroenterologic causes should be determined. When there's complete confusion among these different specialties, there's nothing wrong with the look-before-you-leap of laparoscopy before burning that last bridge of fertility.

Gynecology and Plastic Surgery

Tycho Brahe, a sixteenth-century scientist, was the last of the great naked-eye astronomers. It was upon his work that Kepler was able to determine the orbits of the planets. His contribution to science would fill many books, but instead I'd rather concentrate on his nose.

It seems he lost it in a midnight duel fought over, of all things, a point in mathematics. Whether he was right on the point is irrelevant, for he lost the point on his face. So at age nineteen, he began the rest of his life with a nose made out of metal. I think that there's a fundamental question here that applies today: If beauty is only skin deep--if it's really what's inside that counts--then why would a highly thinking person even of Tycho Brahe's capabilities find it necessary to reform his image to one he felt more acceptable?

Translated: Where does self-esteem end and vanity begin?

Surgery is a major part of the field of gynecology. Most women who develop conditions in which hysterectomy, removal of the ovaries, or bladder suspension become necessary are usually finished their reproductive careers. It's a different phase of their lives where the children are either on their own or at least feeding and dressing themselves. It's a time when parents are getting that first breather from being consumed by their family, instead finally enjoying a different kind of time with them. Fathers and mothers are developing or are rekindling hobbies long neglected by the rigors and duties of raising children right. Surgery, a last resort, will at times inspire a woman to ask herself, "Hmmm, I wonder if I can take advantage of this opportunity to take care of other things." What I'm talking about is the woman who wonders if she can have that tummy-tuck (abdominoplasty) or breast reconstruction at the same time as her GYN surgery.

The answer of course is yes, but it's not as simple as that. There are many considerations that must be weighed in her mind. First of all there's the financial. Usually her insurance will not pay for the added plastic surgery, even if it were to replace her nose with metal. So the fee to the plastic surgeon, as well as for the extra anesthesia and operating room time will come right out of the family pocket. But although this results in a larger financial responsibility, adding those extra minutes to an on-going anesthetic and to an already occupied operating room costs less than what that time would have cost in a plastic procedure all by itself. Certainly the days spent in the hospital for the gynecology surgery wouldn't be any more with the plastic surgery, because cosmetic procedures are usually done on an out-patient basis anyway. This recovery tends to get lost in the shuffle of the GYN recovery hospitalization, with the added benefit of the recovery from the plastic surgery being more comfortable because of the pain management already in place for the GYN procedure.

So financially as well as from a comfort stand-point, it's a good deal.

The next consideration is adding yet another doctor to the mix. This means double the pre-op appointments, double the post-op appointments, and double the synchronization headaches in getting two different doctors from two different specialties to the same place on the same day.

Enter capitalism. Doctors do this for a living, and where's there's a will, there's a way. The doctors will work it out.

I saved the most controversial consideration for last. The question of vanity versus self-esteem may be a hollow argument, however, because it's all relative. Why is a breast augmentation criticized, yet someone having a "bad hair day" is beyond reproach when sinking the family cash into the hair salon? A nose job, metal or otherwise (rhinoplasty, if you don't mind) is scorned as not being satisfied with the way you're "supposed to be," yet not even the critics of plastic surgery feel they themselves are "supposed to be" less attractive than they could be. They live this belief in their clothes, their clean cars, their dental work, but they slam on their idealistic anti-lock brakes when it comes to alterations of one's body. Grooming is one thing, they may say, but changing your body by surgical means is quite another. Of course we live in a society where pierced ears are the norm. If we took all of the critics of plastic surgery and then eliminated all of those who nuke their skin with a suntan, dump fat and cholesterol into their systems with cheeseburgers, gunk up their lungs with cigarette smoke, put their bodies at great risk by not wearing seatbelts, go on unreasonable crash diets for cosmetic effect...well, you get the point.

If you eliminated all of those who risk their bodies in ways others deem reckless, then there would be no critics of plastic surgery left. In a self-indulgent society such as ours, we all live in glass houses. I myself am a big fan of self-esteem. Anything that makes someone feel better about himself or herself is O.K. with me, because there's more happiness there. That means that more people, feeling better about themselves, will treat me better, too.

The world only stands to improve with more people in it who feel better about themselves.

Speaking specifically of gynecology and women seeking plastic surgery, let's think about what these women have done. They've had their babies, worked hard, and ransacked their bodies in the pregnancy gulag. They've done for this one and done for that one, unselfishly, for a long time. It's pay-back time, isn't it? It's time they thought of themselves for a change.

Let's go beyond the mere fine-tuning of self-esteem. What about people who feel they're downright ugly. There is no way anyone else can relate to the suffering that accompanies those who stand out with undesirable features. Criticize all you want, but surgical revision can be the lifetime deal-breaker in one's happiness. Besides the cruelty of children to other children, the uncaring indifference from other adolescents, or the unfairness that all aging people are not created equal under the ravages of Time, there's also that empty, cold feeling--that hurt--when one is ignored because he or she is too fat, short, bald, or badly featured. And no matter what one's accomplishments or foundations of moral fiber, there's still a racism of sorts committed by the beautiful people in acts of omission to others.

It really doesn't matter whether it's a tummy-tuck, a liposuction, a breast alteration, or even smelting a metal nose; if an inevitable GYN surgery offers an opportunity for a woman to increase her feelings of well-being, then her gender and what she does because of her gender prohibit any disapproval.

Advances in GYN Surgery

Advances in GYN Surgery Make Just Last Year Look Like "The Old Days"

"Back in the old days..." we often hear someone say, as we groan in expectation of tales of trips to school by foot in the snow, of times before color television, even before television itself. OB-GYN doctors hear the same phrase, but the difference is that we speak of only a few years ago for most therapies and techniques, even only a year ago for others. "Back in the old days" may only mean last year as we combine several old tricks in new ways. The amazing strides that have taken place in all aspects of the medical, obstetrical, and surgical care for women have kept today's women's care specialists jockeying for position to keep up. Some new skills are picked up by reading the journals, others by watching videotapes or attending seminars, while a few can only be performed by hands-on experience with other physicians.

One of the hottest techniques is LAVH, or Laparoscopically Assisted Vaginal Hysterectomy. In the past there were two main methods of removing the womb (uterus) when indicated. One was by abdominal operation; the other the so-called vaginal, or "blind" hysterectomy. But there is nothing blind about the latter technique--the uterus is removed by surgery in the back of the vagina, leaving no visible scars and shortening hospital and recovery time considerably. Still, even with the shortened recovery of the vaginal technique, it wasn't until the LAVH was developed that recovery was reduced to an amazing days, instead of weeks. The surgery makes use of the laparoscope, a lighted tube placed in the navel and used to look into the abdomen without a large incision.

There is nothing magical about LAVH. It is still a vaginal hysterectomy. The difference is that most of the top portion of the uterus is disconnected using burning or stapling techniques through the laparoscope and an extra tiny slit in the skin or two. This makes removal of the remaining portion of the uterus much less traumatic during that portion of the procedure when the laparoscope is turned off and the vaginal work begins. This lessened trauma-- crushing and tying off of lesser amounts of tissue--accounts for the faster recovery time. While a vaginal hysterectomy patient may leave the hospital on post-operative day two or three, an LAVH patient may be out by the next day! She may be back to work in a week. This is certainly a change from the convalescence of the "old days," where women lay in bed for five to seven days before going home. And probably the best thing about LAVH is that it makes a vaginal hysterectomy candidate out of someone who otherwise could have had only abdominal surgery because of a history of scarring or previous pelvic operations.

Recently, the philosophy of all surgeries has followed the trend of getting people up and about in shorter and shorter times. Whereas a D&C patient had to be subjected to vaginal packing and spending the night at the hospital, today a patient goes to the surgicenter that morning, has the procedure, and leaves later the same morning. She returns to work the next day. Diagnostic laparoscopies for endometriosis have enjoyed the same success. Indeed, out-patient surgicenters have done much to improve the attitudes toward convalescence. They have turned what used to be a hospital incarceration into an easy, comfortable errand.

Pain has not been the same either. Newer techniques by up-to-date anesthesiologists have allowed patients to "cruise" through most routine pelvic surgeries. In my experience, three main improvements in managing post-operative pain have taken us right out of the past--the "old days"--and into the future.

One is the epidural. Long championed by those mothers who chose to have pain relief during their labor, I began using it for GYN surgeries years ago. With it, the patient is given additional sedation, but is usually awake and alert by the time she returns to her room. There isn't that coma-like hangover that general anesthesia produces. Also absent are the difficulty in deep-breathing necessary to prevent lung complications following any surgery. Duramorph, a morphine product placed in the epidural catheter at the end of surgery, continues the absence of pain without interfering with movement. And it can last for 24 hours. Besides Duramorph, a host of other agents can be used through the epidural.

The second milestone in pain relief is the PCA pump--a Pulse Controlled Anesthesia device that slowly drips minuscule amounts of pain reliever into the IV, but which also has a patient-controlled button to add a burst when pain starts to become bothersome. In cases wherein epidurals were not performed, the PCA pump is a deal-breaker when a patient considers whether her experience was pleasant or an ordeal.

The third milestone is use of non-steroidal anti-inflammatory drugs (NSAIDs). Given after a surgery for 24 hours, they put the icing on the cake in pain relief, whether a patient has had a general anesthetic and PCA pump, or whether she has had an epidural with Duramorph.

Certainly, anesthesia and surgical technique go hand in hand. And the breathtaking strides in both have had a happy meeting in the operating room for the female patient. Surgical techniques that minimize trauma to tissue, make possible even gentle tissue handling, and new attitudes about convalescence, are enhanced even further by the newest anesthesia techniques. Certainly the gynecologist's use of the laparoscope is the major player in modern surgery for the woman, but all specialties interrelate to make any indicated surgery not the feared "going under the knife" that it used to be.

Removing Ovaries

Whether a woman may need a hysterectomy (removal of the womb), whether it's merely indicated but not necessary, or whether it's totally unnecessary, is a hot and controversial subject on today's health book circuit. But one side issue of this is often overlooked, so let's bypass all of the rhetoric about whether a woman needs a hysterectomy. There are many good reasons to have one and many good reasons not to have one, too. Instead, I'd like to concentrate on whether routine removal of the ovaries along with a hysterectomy (removal of the womb) is a good idea.

Here's the logic doctors may use: If the average age of menopause is 51, then a woman benefits with removal of her ovaries if she has a hysterectomy in her middle or late forties. After all, if she's only got a few more years--or even months--of ovarian function left, then all the ovaries provide after that is a site for possible ovarian cancer in the future. Using this rationale, there has developed in this country a thinking that under the age of 40, keep the ovaries in at time of hysterectomy; after the age of 45, take them out as a preventative measure against cancer; and between the ages of 40 to 45, let the patient use her own judgement. Unfortunately, this argument falls apart when the people in academics apply their statistics.

First of all, the chance of developing ovarian cancer decreases as a woman gets older. This speaks against "taking them out anyway" if older than 45. Also, and we don't know why, but women who have a hysterectomy while keeping the ovaries has a decreased chance as well. This also speaks against taking advantage of the planned surgery to add the convenience of removing them. In Menopause Management, the author, Dr. Winnifred Cutler (Ph.D., not M.D.) concluded that 400 unnecessary procedures of removing the ovaries would have to be done to prevent one case of ovarian cancer each year. It hardly makes sense... unless you're that one in 400!

I didn't mention that Dr. Cutler was a Ph.D. instead of an M.D. to pull rank of any kind. It's just that the doctors out in the real world sometimes see things differently than those who do research. That one woman out of 400 who gets the ovarian cancer is a mark on a graph to a researcher; we doctors, on the other hand, see her, her family, and her friends repeatedly over the years. This woman is not a smudge on the statistical table along with that researcher's coffee stain--she is a person who comes to me for help. She's got plans. And she probably doesn't give a hoot about the other 399 women who had their ovaries removed unnecessarily. Now before we get into ivory tower bashing, let's recognize that no legitimate methodologies of medicine are developed without research, statistics, and a logic applied to the results. One of the arguments against preventative removal of the ovaries is the advance of osteoporosis if a woman takes no estrogen after. And the role of something called DHEAS, which is a precursor to the other hormones, is all the rage in the media and herbal stores. We know that it falls with removal of the ovaries, and we admit that the long-range effects of this decrease are not known at this time.

If removal of the ovaries costs an insurance company an extra $300 per hysterectomy, then is $300 x 399, or $119,700, not worth that one woman spared ovarian cancer? Have we now set an actual dollar value on a woman? Or are we doing unnecessary castrations as a "good idea" on women based on fear of the occasional bad luck we know some of our patients will have.

Luckily, family history can play an important role in determining a risk of ovarian cancer. The greater the number of relatives who have had this life-threatening condition, and the more closely related they are to the patient, the higher the risk. Perhaps that "under 40, over 45" formula makes sense if the misfortune of ovarian cancer has hit close to home for a patient.

Another factor not taken into account in the journals is how miserably a woman can suffer from recurrent cysts of her ovaries. Fortunately, most women have ovaries that function just fine without any foul-ups. But some suffer with continuing cyst-formation, putting them on an endless merry-go-round of hormonal suppression, scans, exams, laparoscopic evaluations, and larger surgeries. Indeed, if a chronic cystic degeneration is what's left of an ovary in a woman just before the menopause who's having a hysterectomy anyway, is that ovary functioning all that well in the first place? The jury's still out on this one. Most women who have had "everything out" have never regretted it. But might they have felt just as good stopping at just the hysterectomy, since the uterus was the culprit necessitating surgery in the first place? Probably so. I suppose medicine is still an art out here in private practice. We rely on the people in academics to show us reason, meaningful logic, and sound judgment in practicing our art. But it's up to us to breathe the warmth of the doctor-patient relationship into the cold statistics that are the supportive architecture of our art.

(Cesarean">C-Section-Hysterectomy (Cesarean Hysterectomy)

Besides heavy cancer surgery, a Cesarean Hysterectomy is one of the biggest operations an ObGyn surgeon can perform. In it a hysterectomy is performed after delivering a baby by C-section. The reason it's one of our biggest operations is because the organ being removed is just so big. The uterus, normally no bigger than a pear, is at delivery...well...as big as a baby. And it is well supplied with blood vessels that would strike fear into even a cardiovascular surgeon. There's just a lot more clamping, cutting, and tying then with a "regular" hysterectomy.

There's two to three times the blood loss than usual. There's more chance of transfusion and other complications. But a well-trained Gyn surgeon will usually have a very low complication rate when a patient is selected carefully for this operation. And there are times when a Cesarean Hysterectomy is a good idea.

If a woman desires permanent sterilization and she had indications for a hysterectomy before the current pregnancy (if there's a hysterectomy in her future), then the advantageous combining of delivery with a hysterectomy will make a second hospitalization unnecessary. A Cesarean Hysterectomy will be the two-birds-with-one-stone solution. One hospitalization, one anesthetic, one price (albeit more than a straightforward C-section)--all are considerations that make sense.

Indications for hysterectomy can include pre-cancerous conditions of the cervix, pre-pregnancy heavy periods interfering with work or lifestyle, pre-pregnancy relaxation of the uterus to a point wherein pain begins to cause severe limitations on sex, recreation, or just being vertical.

Sometimes an emergency Cesarean Hysterectomy needs to be done. If massive bleeding at the time of a C-section cannont be controlled, the ultimate solution may be removing the organ that's doing all of the bleeding before the patient dies! Also, with previous C-sections, a patient may present at surgery with a rupture of the old incion site on her uterus to such an extent that it cannot be repaired with any degree of safety toward future pregnancies.

Strangely enough, recuperation from a Cesarean Hysterectomy is easier than from a C-section. This is because there's a lot of discomfort originating from the uterus contracting against that incision used to get the baby out. But with a hysterectomy, there's no uterus contracting. This large organ, normally somewhat flopping around to twang all those sore spots in the abdomen, is missing. And so is a lot of the pain.

Like anything in medicine, when it works well, it works great. And when it doesn't, things can be very bad indeed. Unless one's caught in an emergency situation, patient selection under controlled circumstances can make this bigger operation fairly straightforward.

Pelvic Adhesive Disease (Adhesions)--Hidden Scars Take Their Toll

Whenever anyone has any surgery there is scarring. The only scar the patient sees is on the outside, but there are healing phenomena at work on the inside as well, resulting in internal scarring (adhesions). As a gynecological surgeon, much pelvic surgery I do is actually abdominal. Adhesions are an expected result, but fortunately there are usually no noticeable effects. Occasionally, however, a patient will present with pain from adhesions, the result of bowel or its fatty tissue sticking to pelvic or other abdominal organs, limiting the normal flexibility of their function. For instance, when feces or gas pass an area in the intestinal tract kinked or narrowed due to the distorting affects of adhesions, this area can become inflamed or painful.

There are several ways to treat the pain from adhesions. The best way is to just wait it out, because most symptoms will fade away over time. The main advantage in waiting is that surgery, a quick way to treat the adhesions by actually cutting these internal scars, freeing up the stuck structures, can actually lead to further adhesions. But sometimes surgery is the only answer.

When pain becomes so continuous or frequent that the patient can't enjoy any quality of life--exercise, sex, recreation, or work--and analgesics are being increased such that the patient is at risk for a narcotics problem, surgery needs to be offered. This is usually a joint decision between doctor and patient. The patient knows what she is feeling, and the doctor must be sure that all conservative options have been considered. Laparoscopy, placing a lighted tube into the navel, has been used in recent years to treat adhesions surgically. Laser and other specialized laparoscopic instruments can be used to break up the areas of internal scarring, restoring normal anatomy. The good thing about the laparoscope is that laparoscopy itself seems to cause very little adhesion formation.

When the adhesions are unusually severe or when important structures are involved, making an actual incision appropriate, attention is usually paid to meticulous technique, since most adhesions seem to develop due to tissue damage. It seems the actual healing process causes the adhesions; the damaged tissue seeks to seal itself off by joining to other sites. Two preventatives that have been used in the past are Hyskon and Intercede. Hyskon is a sugary substance left as a puddle in the abdomen, the internal tissues forced to slide around so they can't stick. Intercede is a cloth-like absorbable substance. Wrapped around traumatized structures, it converts to a gelatinous barrier to protect the tissue. These two and other techniques have had mixed success in preventing adhesions, so some doctors routine use them, others have discontinued using them.

The worst complication of adhesions is obstruction, the bowel being blocked, which is an emergency. This is rare as a result of GYN surgery, but no one has any special protection from complications. This is why I always run through my list of all scary possibilities before considering surgery on anyone. Is the surgery necessary? Is it indicated? If not, common sense directs us otherwise; but if so, the patient should have no unreasonable fear about surgery, because it is a legitimate therapy.

All medical management is based on risk versus benefit, and nothing exemplifies this more than treatment of adhesions.

Post-operative Considerations--Healing and Convalescence

Doctors Make the Most of Those Daily Visits After Surgery

When a patient undergoes GYN surgery in the hospital, be it a hysterectomy or other pelvic surgery, she usually sees the physician daily during the post-operative period. The gynecologist asks how things are going, flips through the chart, listens with a stethoscope, does a cursory exam, and then the patient is once again left with the nurse's button and bad cable. What may seem like a brief social visit accented by a few prods and pokes is really an important part of the surgery itself, packed economically with crucial information for the physician.

There are many complications that can occur as a result of surgery. Of course in my field, I'm talk about gynecological surgery. "Rounds," as they are called, are post-op visits to the patient designed to recognize or avert these complications. The big three, the complications GYN surgeons are most sensitive to, are bleeding, infection, and damage to structures other than the object of the surgery.

Bleeding:

Whenever there's an incision, there's bleeding. Good surgical technique involves controlling blood loss while surgery is performed, and seldom are GYN patients transfused. In fact, we hate the thought of transfusion. Even though the blood supply is "considered" safe, nevertheless we have heightened our sensitivities regarding giving blood. This doesn't mean, however, that we're afraid to give it if needed.

Infection:

Any time the skin is breached, the normal abilities to fight infection are compromised. Sterile body environments are entered and exposed to outside air and ambient micro-organisms. True, sterile procedure is strict policy, but the patient can be subject to the invasion of isolated bacteria--even from herself. In most cases, the immune system is more than adequate to ward off infection, but occasionally strong antibiotics become a part of a patient's convalescence.

Damage to Other Structures:

GYN surgeons are particularly sensitive to the urine collecting system. This is because pelvic surgery is close to urinary structures. Surgical technique involves identifying these structures for their protection, but distortion of anatomy due to abscess, endometriosis, or scarring can make this an accepted complication in some cases.

When a doctor makes rounds, these and lesser complications are considered in a sort of mental checklist. Progress notes document the assessment in the chart as a permanent record. Is the urine output adequate? Is it bloody or clear? Is there a fever? If so, is it from the site of surgery, or are the lungs a little junky because the patient can't deep breathe without expected discomfort? Is a low grade fever from a simple bladder infection, or is it the beginning of something worse? Should the surgeon wait and see or commit the patient to a few days of intravenous antibiotics? At what point should the patient be fed without a build-up of gas pain (the REAL pain after any pelvic or abdominal surgery)? Behind the smiling hello and brief encounter lies a whirring mind going through mental check-lists and flow-sheet decisions that are designed to get a patient recovered as soon as possible with a minimum of discomfort and maximum of safety. A patient may feel she is on "auto-pilot" at this point of her recovery, but to a surgeon the surgery is still going on until she can leave the hospital and resume her activities.

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