1. Introduction: The Evolution of a Surgery

For nearly a century, the medical community’s answer to breast cancer was defined by Halsted’s radical mastectomy. This aggressive procedure prioritized survival at any cost, often leaving women with profound physical and psychological scars. While the transition to Breast-Conserving Surgery (BCS) offered hope, many patients still faced a cruel choice: effectively remove the cancer or preserve the breast’s natural shape.

Today, a revolutionary approach known as Oncoplastic Surgery (OPS) is dismantling this old dichotomy. Often called the “third pathway,” OPS bridges the gap between traditional lumpectomies and full mastectomies. It allows us to move beyond simple survival, addressing the fear of deformity by treating the tumor and the woman’s body image as one inseparable priority.

2. The “Third Pathway”: More Than Just a Middle Ground

Oncoplastic surgery is the strategic integration of plastic surgery techniques at the same time as tumor removal. Instead of merely closing a “hole” left by a lumpectomy, surgeons use reconstructive principles to immediately reshape the breast. This shift in philosophy treats “psychological morbidity” as a primary concern, recognizing that a woman’s quality of life is tied to her physical sense of self.

By rearranging the remaining breast tissue, known as the parenchyma, surgeons can ensure a homogenous redistribution of volume. This prevents the “divots” and retractions that historically signaled a cancer surgery. This isn’t just a middle ground; it is a superior surgical evolution.

“OPS is the ‘third pathway’ between standard BCS and mastectomy. The OPS classification and Atlas improves patient selection and allows a uniform approach for surgeons… it proposes a specific solution for different scenarios and helps improve breast conservation outcomes.”

3. The Surprising Math of Volume: The 1,000-Gram Threshold

In conventional BCS, the average specimen removed weighs a mere 20 to 40 grams. Historically, 80 grams was considered the absolute maximum weight that could be removed from a medium-sized breast without causing visible deformity. OPS completely rewrites these mathematical constraints, allowing for significantly larger excision volumes.

The 20% Rule Clinical evidence indicates that once tissue removal exceeds 20% of the breast volume, deformity is nearly certain. However, level II OPS techniques allow surgeons to remove 200 grams, and in some cases up to 1,000 grams, without compromising the aesthetic result. This counter-intuitive reality—removing more tissue to achieve a better look—is possible because the breast is engineered into a new, albeit smaller, mound.

4. Density Matters: Why Your BI-RADS Score Changes the Scalpel’s Path

A patient’s glandular density, categorized by BI-RADS scores, is the hidden blueprint for surgical success. Dense breasts (BIRADS 3/4) are generally more “forgiving” for Level I OPS, which utilizes dual-plane undermining. This technique involves separating the breast tissue from both the skin and the chest muscle to allow for better mobilization.

However, for patients with fatty breasts (BIRADS 1/2), dual-plane undermining is dangerous and can lead to fat necrosis. For these women, moving directly to Level II OPS is often safer because it leaves the skin attached to the gland, preserving the essential blood supply. Surgeons must also weigh several patient-related risk factors:

• Smoking history (the primary risk for necrosis)

• Obesity (High BMI)

• Diabetes

• Previous radiotherapy or breast surgeries

5. Avoiding the “Bird’s Beak”: Engineering the Perfect Shape

The “bird’s beak” deformity is a classic failure of traditional surgery in the lower pole (6 o’clock position). It occurs due to the retraction of the skin and downward deviation of the nipple-areolar complex (NAC). To prevent this, surgeons use Level II techniques—exchanging 20% to 50% of the breast volume to maintain a natural projection.

Different quadrants require specialized engineering to ensure the nipple remains centered on the new breast mound:

1. Superior Pedicle Mammoplasty: The gold standard for preventing “bird’s beak” in lower-pole tumors.

2. Batwing Mastopexy: Ideal for central or upper-inner tumors to preserve the “décolleté” line.

3. Racquet Mammoplasty: Designed for the “forgiving” upper-outer quadrant using a radial scar.

4. Round Block (Benelli Technique): A versatile approach for upper-pole tumors that leaves only a periareolar scar.

5. Grisotti Technique: A specialized solution for central tumors that allows for immediate NAC reconstruction.

6. Survival vs. Aesthetics: A False Dichotomy

A common fear is that focusing on aesthetics might allow cancer to hide or spread. However, the data is clear: OPS maintains equivalent local and long-term survival rates compared to mastectomy. In fact, OPS often results in lower rates of positive margins because the surgeon has more “oncological room” to work.

By removing a larger “safety envelope” of tissue, surgeons reduce the need for traumatic re-excisions. We are finding that when we have the tools to reshape the breast, we are actually freer to be more aggressive in removing the cancer.

“Oncoplastic breast surgery allows wide local excision of the mass with good cosmetic results… results in lower mastectomy rates with equivalent local and long-term survival rates as compared with mastectomy.”

7. Timing the Recovery: Immediate vs. Delayed Reconstruction

The choice of timing often revolves around the need for Radiotherapy (RT). While immediate reconstruction is the hallmark of OPS, certain cases require a delayed approach to allow skin changes from radiation to stabilize.

Feature	Immediate Reconstruction	Delayed Reconstruction
Number of Operations	Single stage	Multiple stages
Patient Benefits	Shorter stay; higher self-esteem	Planned around RT skin stabilization
Primary Risks	Skin/flap necrosis	Loss of natural anatomical features
Surgical Goal	One-stage recovery	Stabilized result after adjuvant therapy

Oncoplastic techniques actually make radiotherapy safer and more precise. By using clips to consolidate the tumor bed into a “single boost area,” radiation oncologists can target the cancer’s former home with pinpoint accuracy, sparing the healthy surrounding tissue.

8. Conclusion: The Future of the Whole Patient

The rise of oncoplastic surgery proves that we no longer have to sacrifice the woman to save the patient. By improving Quality-of-Life indexes, OPS ensures that “body image” is not a luxury, but a vital component of recovery. Clinical failures in this field rarely stem from the science itself, but from a lack of judgement and planning in the pre-operative phase.

As we look toward the future, we must challenge the medical community’s definition of “success.” If a patient survives but is left with a permanent reminder of her trauma in the mirror, have we truly succeeded? The “oncological room” provided by OPS suggests that the most successful surgery is the one that prioritizes both survival and the psychological wholeness of the person behind the diagnosis

Here is a comprehensive patient education guide regarding exercises following neck dissection, based on the provided clinical sources.

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Introduction

Recovering from neck dissection surgery involves more than just healing the skin incision. During surgery, the spinal accessory nerve—which controls the shoulder muscles—may be stretched, bruised, or removed. This can cause the trapezius muscle to weaken, leading to stiffness, aching, and difficulty lifting your arm above your head.

The following protocol is designed to prevent stiffness, reduce pain, and restore your range of movement.

General Safety Guidelines

• When to Start:
  • Days 0–4: Rest. Do not perform exercises yet.
  • Days 5–9: Start exercises slowly and in a controlled manner.
  • Day 10 onwards: You should begin to regain your normal range of movement.
  • Note: Your physiotherapist will guide you on exactly when to start, usually once neck drains are removed.
• Pain vs. Stretching: Exercises should not be painful. A feeling of “stretching” or tightness is normal, but if you experience sharp pain, stop immediately and consult your team.
• Lifting Restrictions: Do not lift anything heavier than 1kg (approx. 2.2 lbs) or 3 lbs (e.g., a steam iron) for 6 months after surgery unless advised otherwise. Avoid heavy shoulder bags on the operated side.
• Frequency: Exercises are most effective when done “little and often.” Aim for 5 repetitions of each exercise, 3 to 5 times per day.

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Phase 1: Posture and Positioning

Good posture prevents chest tightness and muscle strain.

The “String” Technique: Imagine a piece of string attached to the top of your head is pulling you gently toward the ceiling. Keep your head in line with your neck and shoulders, and keep your shoulders back and relaxed.

Sleeping Position: Lie on your back as much as possible. If you must lie on your side, lie on the unoperated side with your operated arm resting on a pillow in front of you. Do not lie on the operated side unless cleared by your surgeon.

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Phase 2: Neck Exercises

Perform these slowly. Hold each position for 3 to 5 seconds.

1. Neck Flexion (Looking Down)

• Instruction: Sit comfortably. Tilt your head down, tucking your chin toward your chest.
• Variation: Look down toward your armpit on the side opposite your surgery for a gentle stretch.

2. Neck Extension (Looking Up)

• Instruction: Tilt your head back, pointing your chin toward the ceiling. Keep your lips closed.
• Support: You may support the back of your head with your hands for stability.

3. Neck Rotation (Turning Head)

• Instruction: Turn your head to the side as if trying to look over your shoulder. Repeat on both sides.

4. Side Flexion (Ear to Shoulder)

• Instruction: Tilt your head to the side as if trying to touch your ear to your shoulder. Keep your shoulders relaxed; do not shrug them up to meet your ear.

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Phase 3: Shoulder Rehabilitation

The spinal accessory nerve affects shoulder function. These exercises are critical for regaining overhead reach.

5. Shoulder Shrugs (Elevation)

• Instruction: Lift your shoulders up toward your ears as far as you can. Hold for 5 seconds, then relax them down completely.

6. Shoulder Blade Squeeze (Retraction)

• Instruction: Keep your elbows close to your body and bent at 90 degrees. Squeeze your shoulder blades together behind your back. Do not lift your shoulders up.

7. Forward Arm Lift (Flexion)

• Instruction: Start with your arm by your side. Lift your arm out in front of you as high as you can, aiming to get it above your head. This can be done standing or lying down.
• Variation: If lying down, use your unoperated hand to support the operated arm as you lift it toward your head.

8. Wall Climbs (Pinky Slides)

• Forward: Stand facing a wall. Place the side of your hand (pinky finger) against the wall. Slide your hand up the wall until you feel a stretch.
• Sideways: Stand with your operated side toward the wall. Slide your hand up the wall sideways to stretch the shoulder.

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Phase 4: Strengthening and Advanced Stretches

9. Chin Tuck (Deep Neck Strengthening)

• Instruction: Pull your chin straight back as if trying to make a “double chin.” Do not tip your head forward. Hold for 5 seconds.

10. Doorway Chest Stretch

• Instruction: Stand in a doorway with your forearms resting on the doorframe at shoulder level. Gently step forward until you feel a stretch across your chest.

11. Jaw Lowering

• Instruction: Place the tip of your tongue behind your top teeth. Slowly open your mouth while keeping the tongue in place. Use a mirror to ensure your jaw opens evenly.

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Scar Massage

Once your wound is fully healed (no open areas, redness, or scabs), scar tissue may feel tight.

• Technique: Use a non-perfumed cream. Massage the scar using circular, up-and-down, and sideways motions with firm pressure.
• Duration: 10 minutes, 2 to 3 times per day.

Other useful exercises:

When to Contact Us

If you experience any of the following, stop exercising and contact the head and neck therapy team or your surgeon:

• Persistent pain or swelling.
• Dizziness or nausea during exercise.
• Inability to move the neck or shoulder after 3 months of consistent exercise.

Exercises are required for following reasons:

• Avoid deep vein thrombosis
• Improves circulation to muscles
• Light exercises improve healing and prevent hernias.
• Exercises to pelvic floor
• Deep breathing exercises helps in lung expansion, better oxygenation and early recovery
• Ambulation and exercises makes early return to intestinal motility

Recovery time after the abdominal surgery is approximately one month.

During this time you have to avoid lifting and carrying heavy loads (maximum 1-2kg).

Abdominal binder/ belt:

During the recovery time, use the elastic abdominal support belt. You get the belt from the hospital as a loan. If you get any other advice on how to use the support belt, follow it. Before you sit up, put the support belt on and use it when you walk around. 

During the recovery time turn to your side before you sit up and avoid straining your abdominal muscles.

It’s most appropriate to start using an APPROPRIATE size belt from early post operative period.

Walking is the best exercise after surgery. It helps you recover from surgery and regain your previous condition. Make sure that your shoulders are relaxed and try to maintain good posture even if the wound might feel tight. It’s highly recommended to walk daily, extend the walking distance gradually.

Kegels pelvic floor exercises: 

Your pelvic floor may be weakened after a hysterectomy, which can cause temporary loss of bladder control, shifting of pelvic organs and other problems. Kegel exercises are quick contractions designed to strengthen the pelvic muscles. Simply squeeze the muscles you would normally use to stop the flow of urine, release and repeat. 

• Contract your pelvic floor muscles for 3-10 seconds at a time;
• Repeat these contractions for up to 8-12 repetitions in a row for one full set of exercises;
• Perform 3 sets of exercises throughout the day i.e. approximately 20-30 exercises in total;
• Aim to do your kegel exercises every day; and
• Try to make your kegel progressively stronger as your strength improves.

Deep breathing exercises:

Many people feel weak and sore after surgery and taking big breaths can be uncomfortable. Your provider may recommend that you use a device called an incentive spirometer. If you do not have this device, you can still practice deep breathing on your own.

The following measures may be taken:

• Sit upright. It may help to sit at the edge of the bed with your feet hanging over the side. If you cannot sit like this, raise the head of your bed as high as you can.
• If your surgical cut (incision) is on your chest or belly, you may need to hold a pillow tightly over your incision. This helps with some of the discomfort.
• Take a few normal breaths, then take a slow, deep breath in.
• Hold your breath for about 2 to 5 seconds.
• Gently and slowly breathe out through your mouth. Make an “O” shape with your lips as you blow out, like blowing out birthday candles.
• Repeat 10 to 15 times,

Circulation exercises

 These help to maintain the blood circulation in your legs whilst you are not so active. This reduces the risk of getting a blood clot (DVT). 

• Keep your legs and ankles uncrossed at all times

 • With your legs stretched out, briskly circle your feet and bend them up and down.

 Do these every hour while you are awake. You can do these when lying down or sitting in a chair

Basic exercises

 Start with exercises sat in a chair: 

• March your knees alternately for 30 seconds.

• Bend and straighten your knees. 

Hold your knee straight for 10 seconds, keeping your toes pulled up. Repeat 5 times with each leg as you are able.

• Lift your heels and toes alternately for 30 seconds

Once you can do these exercises comfortably, progress to exercises in a standing position. Place your hands on a supportive surface like a kitchen worktop or back of a chair. Make sure your shoulders are not hunched and that you’re standing tall:

March for 30 seconds.

Small squats. Aim to repeat 10 times keeping the movement slow and controlled.

Push up onto your toes 10 times

After 2 weeks post surgery:

you can start exercises for the internal abdominal muscles. The purpose of this exercise is to regain the function of abdominal muscles and to prevent wound hernia.

You should do this exercise 5 – 6 days a week.

Take supine position with knees flexed and arms on your sides. Lift your head during exhale and lay it back during inhale. Repeat exercise at the pace of your normal breathing 3 x 5 – 15 times.

you can also start light stretching for the abdominal muscles. The purpose of this exercise is to restore the elasticity of the abdominal muscles and prevent tension of scar tissue. Stretches should be done after the abdominal muscle exercise (5 – 6 days a week).

Take supine position with arms on your sides. Lift arms over your head during inhale and move them back to starting position during exhale. Repeat exercise at the pace of your normal breathing 3 x 2 – 5 times.

After 6 weeks of surgery

you can start exercises for the external abdominal muscles. The purpose of this exercise is to strengthen your abdominal muscles.

Take supine position with knees flexed and arms crossed over your chest. Arch your upper back during exhale. Your head, shoulders and upper back should rise up from the surface. Relax your muscles and return back to starting position during inhale. Repeat exercise at the pace of your normal breathing 3 x 5 – 15 times. Core Stability Exercises Having major abdominal surgery will affect your abdominal muscles and hence your core stability. To improve your core stability, please do the exercises outlined in the following pages. The best position to do these exercises is lying on the floor. However, if you are unable to do so, you could do them lying on a bed. Aim to do them three times a day. 1. Deep Abdominals• Lie on your back, knees bent, at hip width apart, feet flat • Put one pillow under your head • Breathe in, gently letting your tummy rise • As you breathe out, gently draw your tummy button towards your spine• Hold for a few seconds, then relax • Rest for a few seconds • Repeat 3-5 times  Remember: • Keep your back still • Don’t hold your breath • Build up gradually – holding your tummy in for a maximum of 10 seconds, repeating it 10 times. 2. Pelvic Tilting Lie in the same position as shown. • As you breathe out and draw your tummy in, gently tilt your pelvis and flatten the small of your back into the bed. • Hold for a few seconds, and then relax• Repeat 3-5 times and gradually build up to 10 times 3. Knee RollingLie on your back, knees bent and together, feet flat • Draw and hold your tummy in • Slowly lower your knees to one side, making sure that your shoulders remain on the floor • Return to the starting position • Lower your knees to the other side making sure that your shoulders remain on the floor • Keep breathing normally • Repeat 3-5 times and gradually build up to 10 times

Walking & Yoga:

Aim to walk every day gradually increasing the distance. You should aim to be able to walk 30 minutes daily by one to two months after your operation. Start walking on level ground and gradually build up to inclines and uneven ground such as cobble paths. Walking on uneven surfaces requires small changes of direction which can cause some discomfort in the healing abdominal muscles. After two to three months you could consider moderate exercise like swimming or cycling. To progress your core stability exercises you could attend a Yoga or Pilates group. However, seek advice from the group’s instructor about an appropriate level of exercise. If you wish to return to a specific sporting activity please discuss this with your consultant.

You can return to your previous activities after 1 – 2 months.

Exercise summary

Exercises before your operation:

• General exercise

• Deep breathing exercise

• Core stability exercises

Exercises after your operation:

• Getting in and out of bed and walking

• Deep breathing exercises

• Exercises for clearing secretions

• Circulation exercises

• Core stability exercises

Exercises after you have returned home:

• Core stability exercises

• Exercises sat in a chair

• Once comfortable, exercises in standing

• General exercise

Common concerns

1] Urinary issues:

In post operative period urinary catheter is kept for almost 3-5 days. This is useful to reduce efforts of the urinary bladder for voiding as the pelvic nerves are handled during the surgeries. However, patients are advised to performs Kiegel’s exercises regularly after 2nd day.

It strengthens the muscles that support the bladder. Strong pelvic floor muscles can go a long way toward warding off incontinence.

• Pretend you are trying to avoid passing gas.
• Pretend to tighten your vagina around a tampon.

Choose your position. Start by lying on your back until you get the feel of contracting the pelvic floor muscles. When you have the hang of it, practice while sitting and standing.

Contract and relax

• Contract your pelvic floor muscles for 3 to 5 seconds.
• Relax for 3 to 5 seconds.
• Repeat the contract/relax cycle 10 times.

Keep other muscles relaxed. Don’t contract your abdominal, leg, or buttock muscles, or lift your pelvis. Place a hand gently on your belly to detect unwanted abdominal action.

Extend the time. Gradually increase the length of contractions and relaxations. Work your way up to 10-second contractions and relaxations

Aim high. Try to do at least 30 to 40 Kegel exercises every day. Spreading them throughout the day is better than doing them all at once. Since these are stealth exercises that no one notices but you, try to sneak in a few when waiting at a stoplight, riding an elevator, or standing in a grocery line.

Diversify. Practice short, 2 to 3 second contractions and releases (sometimes called “quick flicks”) as well as longer ones.

2] sexual dysfunction:
The surgery affects the sexual function in 2 ways. One being removal of ovaries surgically or damage to ovaries by chemotherapy or radiation and thus the production of estrogen and progesterone are halted. Another way is changes in female reproductive system post surgery leading to shortening of vagina, loss of uterus etc. however, the painful sensation wanes completely in 3-4 weeks and thereafter dyspareunia i.e. pain during intercorse goes off.

3] Stress urinary incontinence:

The injuries to autonomic nerves during surgery or advanced cancers involving these nerves can lead to post op leaking of few drops of urine during vigorous activities like jumping or coughing etc. the only good known remedy for it is to do kiegel’s exercise as described above.

4] Bedsore:

Elderly patients need to be nursed with frequent change of positions as the same position puts pressure at bony prominences in contact with mattress. Due to poor blood supply and skin quality, bedsores may crop up as no surprise. Skin care with appropriate moisturisers, powders, prevention of maceration due to sweat are of utmost importance. At times water or air beds need to be used.

5] Vaginal hygiene:

Post surgery there could be thin discharge from healing tissues. It needs to be cleaned with clean water and soap and maintain local hygiene. Commercially available neutral pH soap solutions are good and gentle on this body part.  If the discharge is smelly or white curdy colour then please consult doctor as it needs Rx

6] Suture care: 

The healing scar needs to be kept clean and tidy. Our preferred way is to keep it open and dry to air. Patient needs to inspect the wound twice a day and look for any redness or discharge from the wound. patients should take wash or bathe over the wound and even apply soap and water on it. Please make sure to dab the scar to dry and apply alcohol based sanitizers or chlorhexidine based sanitizer to skin around the scar. Sutures are usually removed after 2 weeks i.e. 14 days post surgery. In case any issue is noted at scar, click a photo and send to clinic number 9819073781 or e-mail on oncosurgeon.hp@gmail.com.

Don’t forget to ask Dr at postoperative follow up:

1] condition of surgical site

2] histopath report

3] stage

4] further treatment ie chemotherapy, radiotherapy etc

5] prognosis

6] follow up plan and investigations at follow up

Investigations for gynecological cancers: checklist

A] For diagnosis:

• Cervical cancer: PAP smear, Cervical biopsy or endocervical curettage.
• Endometrial cancer: dilatation and curettage
• Ovarian cancer: ascitic fluid cytology or FNAC or Tru cut biopsy of ovarian mass or deposit.

B] Metastatic work up:

Whole body PET CT. or, CECT abdomen and pelvis, Ct chest

C] Local extent or resectability:

•      MRI pelvis with CECTAbdomen/ whole body PET CT: in case of cervical or endometrial cancer
•      CECT abdomen and pelvis or whole body PET CT: for ovarian cancer.

D] for assessment of fitness for surgery:

❏  CBC/ hemogram,

❏  LFT [liver function tests],

❏  RFT [renal / kidney function tests],   

❏  PT,PTT,INR  [coagulation profile],

❏  BG: blood group

❏  Random blood sugar, Urine routine examination,

❏  Viral markers: HIV, HCV, HBsAg

❏  Cardiac assessment: Chest X Ray, ECG, 2D ECHO

❏  Other tests as per individual risk factors

❏  Fitness evaluation from Physician and anesthesiologist

Declare:

 ❏  Previous surgeries– be it any,

❏  Allergies: drug allergy, sticking allergy or any substance allergy.

❏  Comorbidities like hypertension or high BP, diabetes, previous heart attack, arrhythmias, previous cardiac stenting or bypass surgery, asthma etc

❏  If you are taking blood thinner [commonly used being aspirin or clopidogrel], it needs to be stopped at least 5 days prior with your cardiologist’s advice.

❏  Policy for blood reservation: usually blood transfusions are not needed in this surgery unless the patient has anemia in pre op assessments. However on the safer side blood is reserved so it can be given in untoward emergencies.

Pre surgical checklist:Dos & Don’ts 

Pre-Operative

❏Blood thinners: Stop clopidogrel, aspirin or similar medications prior to the surgery with the physician’s advice.

❏Nil by mouth & Bowel preparation: In anticipated major or supra major surgeries and those involving surgery on rectum or colon or small intestines, emptying of intestines by medications &/or enemas are given. 

The Peglec powder is to be mixed in water with strong lemon juice to make it acceptable and mask its taste. Such 1 lt solution is to be consumed sip by sip over one hour an evening prior to surgery. Patient  would thereafter pass stools and the intestines would be cleansed medically thereby. She can consume clear liquids till midnight or 6-8 hrs scheduled time of surgery. Patients need to maintain 8 hours of fasting prior to surgery, conventionally. The newer ERAS protocols allow the patient to take clear energy drinks containing glucose, salts etc upto 4-6 hrs prior to surgery. The RMO or Nurses would communicate the plan for you

❏Shower: 

Shower the night before and the day of surgery.

 • Use approximately one ounce of antiseptic soap (CHLORHEXIDINE OR SAVLON      soap :  30 ml), washing below the neck only. You may use your regular soap / shower gel or shampoo for face and hair.

 • Rinse well.

 • Repeat above steps.

 • Use a freshly laundered towel to dry off after each shower.

 • Put on freshly laundered garments (night clothes, underwear, etc.).

 WARNINGS – This soap is for external use only. DO NOT USE ON FACE. Keep soap out of your eyes, ears, and mouth. Misuse around eyes could cause serious and permanent eye injury. If soap should contact the eyes or ears, rinse out thoroughly and promptly with water. NOT for use as a shampoo or douche.

❏Arrange for a family member, friend or near keen to bring you to the hospital, sign consent as a responsible and near relative.  

❏The secretary from the Suyog Cancer clinic or RMO doctor will get in touch with you in the evening before surgery to confirm time and location for check in for your surgery. If you have not received a call by 4 p.m., you may call on 9819073781 . 

❏Please discuss any medications you usually take in the morning with the on duty RMO at hospital.

 Day of Surgery   

❏  Leave jewellery and valuables at home.  NO METAL CONTAINING THING ON PATIENT’S BODY DURING SURGERY like chain, ear ring or rings in toes, bracelet etc

❏  Wear your glasses instead of contacts if you have them. Hand it over to relatives before entering the operating room.

❏  Please do not use deodorant or lotions on your skin and nail paints too.

❏      Avoid using hair spray or gel.

❏      Wear comfortable clothing and hospital clothings only.

Post surgery: 

•  Food after surgery: depending on extensive surgery, Dr and nurses will inform about food intake. Usually, patients are kept nil by mouth for 8-12 hours. Thereafter clear liquids are started as per patient’s tolerance. If no intestines are operated during the surgery, semisolid foods are given on day 1 or 2 and slowly escalated towards solids and normal diet.

•  Position after surgery: Better to remain 30- 45 degree head and back inclined up till full recovery.

•  Post op treatment: Nurses will give the IV fluids as per instruction and sugars will be timely checked as ordered. Antibiotics,anti acidity  and pain medications will be given for 1-3 days and oral medications thereafter.
• Epidural catheter: there could be a tiny bore tube inserted before surgery into the spine by an anesthesiologist, called an epidural catheter. It is used to deliver medicines to alleviate pain post surgery. It is usually kept in place for 3 days after surgery.

• Patient’s previous medicines for comorbidities like blood pressure or diabetes etc can be resumed after the physician’s advice.

• Dressings & Suture removal: Dressing will be changed before discharge. It is advisable to actively learn and follow the dressing technique so relatives can do it at home as required. My patients are advocated to take bath with soap and water over the surgical clips, keep it clean and observe it thereby, if need be , click a photo and send across for any concern. Clips are usually removed after 14 days post surgery.

Post anesthesia recovery symptomes: 

You may feel drowsy and have minor side effects after your procedure or surgery with anesthesia. These side effects include:

• Sore throat        • Headache        • Muscle aches • Dizziness off and on

• Nausea               • Vomiting (rarely) 

Some of these symptoms may be from the pain medicine you are taking. The side effects from anesthesia usually go away quickly in the hours after your procedure. Still, it may take several days for your body to recover from the stress of surgery and anesthesia.Urination: there would be a urinary catheter for 3-5 days post surgery. So patients need not get out of bed for micturition.

There are 3 main types of cancers under this heading ie cancers of female reproductive system viz 

1. Cervical cancer
2. Uterine or endometrial cancer
3. Ovarian cancer

There are few other cancers too like vulvar cancers and vaginal cancers. Let’s discuss the common 3 gynecological cancers and their Rx plan with special reference to surgery and preparedness for the same.

Gynecological cancers are managed with multimodality therapies like surgery, chemotherapy and radiotherapy. The sequence and/or combination of these are used as per the stage and patient related factors, which is known as personalized or precision medicine in cancer care. Surgery remains the mainstay of therapy in gynecological cancers. Chemotherapy and radiation are used as adjunct treatments in many of the cancers.

Symptoms of common gynecological cancers:

Symptoms of cancers of the female genital tract vary according to the organ of origin of cancer. Most of them remain asymptomatic for a significant period unless regular health check ups are done. Following is the list of symptoms in various cancers of the female genital tract.

Diagnosis:

Diagnosis: 

Ovarian cancer:

• Ca 125
• CECT abdomen and pelvis or whole body PET CT
• Ascitic fluid cytology or biopsy from ovarian mass or deposits

Uterine or endometrial cancer:

• Endometrial biopsy or dilatation and curettage
• MRI pelvis and CT abdomen or whole body PET CT Scan

Cervical cancer:

• PAP smear or Punch biopsy from cervical lesion
• MRI pelvis with CT abdomen or whole body PET CT Scan

Lets understand terminologies

1. Definitive Therapy: usuallySurgery/ Radiation therapy: mainstay of treatment producing maximum benefit for curative intent.
2. Neoadjuvant therapy: usually chemotherapy, given to decrease extent and size of disease bulk
3. Adjuvant therapy: additional treatment for additional benefit to prevent local or systemic recurrences and improve disease free survival
4. Metastatic: disease stage in which cancer has spread to distant sites that make it beyond scope of curability
5. Palliative therapy: treatment to the disease that has grown beyond the level of cure.
6. Symptomatic treatment: treatment to alleviate symptoms alone and not aiming to treat disease [that has grown beyond treatable limits], not involving chemotherapy, radiation or surgery, usually tender loving care at end of life.
7. Prognosis: the probability of survival. It’s the gross measure of outcome after treatment of cancer.

It’s important in gynec cancers that multimodality treatments involving surgery, chemotherapy and radiation are offered in the most appropriate sequence and time to get the best results. Your surgeon, medical oncologist and radiation oncologist should so discuss and make a consensus decision.

Cancer	Stage	Neoadjuvant Rx	Definitive Rx	Adjuvant Rx
Cervical	Early		Surgery	Radiation or chemoradiation
	Locally advanced	+/-Chemotherapy	Chemoradiation
Ovarian	Early		Surgery	+/-Chemotherapy
	Locally advanced	Chemotherapy	Surgery	Chemotherapy
Endometrial	Early		Surgery	Radiation +/- chemotherapy
	Locally advanced	Chemotherapy	Surgery	Radiation +/- chemotherapy

Understanding the Surgery for gynecological cancer:

Incision or concern of scar:

Generally for ovarian cancer  the incision of choice is vertical midline and for cervical or endometrial cancers either can be used however the vertical is preferred, especially when removal of abdominal nodes is anticipated.

Extent of surgery for ovarian cancer:

The ovarian cancer surgery encompasses diagnostic laparoscopy i.e. pre operative visualisation of disease for staging via a small cut and a camera. Upon ascertaiong complete operability i.e. having near zero possibility of residual disease left behind, major surgical resection is attempted. The conventional surgery includes removal of ovarian mass with ovaries, tubes, uterus, omentum [fat laden curtain like organ in abdomen that may have cancer cells], lymph nodes in pelvis &/or abdomen, appropriate peritonectomy and excision of all gross disease noted during surgery.

Surgery for endometrial cancer:

The surgery for endometrial cancer involves resection of the uterus with clear margins around and vagina, tubes, both ovaries, lymph nodes in pelvis and sometimes nodes in abdomen too.

Surgery for cervical cancer: Wertheim’s Radical Hysterectomy

Cervical cancer surgery begins with examination under anesthesia, proctoscopy, cystoscopy to rule out invasion into rectum, urinary bladder or sides of the cervix, better known as parametria.

Upon ascertaining resectability, surgery includes removal of the uterus with a wide cuff of vagina and parametrium, tubes, ovaries and bilateral pelvic lymph nodes.

What is lymph node dissection?

The lymph nodes are the filtering stations that harbours first immune power against any harmful agents like bacteria, virus, cancer cells etc. the nodes have immune cells that trap them and prevent them from spreading ahead. In cases of cancer, though the nodes trap cancer cells, they have to be removed for two purposes, one being treatment of cancer spread and second for accurate staging. The figure below shows the propensity or common lymph nodes that can be involved in cancers of the female genital tract. In certain cases of ovarian/ endometrial and cervical cancers, lymph nodes in either sides of pelvis and abdomen [retroperitoneum] are ought to be removed.

Role of laparoscopic or robotic surgery in gynecologic cancers:

The laparoscopy is a great invention that makes patients return early to work and get surgery with much less discomfort. The utility of laparoscopy is debatable in gynecological cancers, hence this modality needs further studies for the approval in gynec cancer surgeries. Until then open surgeries remain the standard of care.

Aim: to suck out the undesirable fluid accumulation in the cavity created post surgery.

Parts: the two tubes are inserted via skin. One in the breast surgery part and another into the armpit. The tubes are secured in place with a suture ligature. The two tubes drain into one via a connector. The tube has a clickable locking mechanism that can open or close the connection of tubes to the vacuumised box. The tube has a detachable connection to the vacuumised box which ultimately stores the unwanted fluid.

Operating the romovac suction drain system:
The box can be emptied upon disconnection from the tube as shown in the picture. The effluent fluid has to be measured by emptying into a measuring jar or any utensil and measured using a syringe.

Precautions:
The drains should not be pulled out as it could be painful and may invite complications like slippage of the drain tube.
It is advisable to keep the drain box and tube into a bag with a medium length belt that can be carried in the neck or shoulder.

Certain exercises are to be avoided when the drain is in place. Please refer to the exercise section for detail.
Avoid swimming, sauna, tub bath, excess hot water bath when drain is in place

Daily charting of the same guides for the timely removal. In usual practice, drains are removed when constantly for 2 days the output is less than 20 ml. The drain removal is done by a doctor or trained nurse. It is a relatively painless procedure.

Date of surgery:  

POD	Date	Daily output [ml]		POD	Date	Daily output [ml]

POD: post operative day

Lymphedema management:

About  lymphedema: 

Lymphedema occurs when the lymph system is damaged or blocked. Fluid builds up in soft body tissues and causes swelling. It is a common problem that may be caused by cancer and cancer treatment. Post therapy, patients may have swelling in the upper limb. It may be perceived as increased girth of upper extremity, heaviness, skin changes in form of fine pitting at hair follicles etc.

Causes of lymphedema:

• Due to extensive axillary dissection→ disruption of lymphatics
• Heavy cancer cell budon blocks the lymph nodes and main lymphatic channels
• Radiation creates fibrosis and destruction of lymphatic pathways.

Precautions: 

Keep skin and nails clean and cared for, to prevent infection.
Bacteria can enter the body through a cut, scratch, insect bite, or other skin injury. Fluid that is trapped in body tissues by lymphedema makes it easy for bacteria to grow and cause infection. Look for signs of infection, such as redness, pain, swelling, heat, fever, or red streaks below the surface of the skin. Call your doctor right away if any of these signs appear. Careful skin and nail care helps prevent infection:

• Use cream or lotion to keep the skin moist.
• Treat small cuts or breaks in the skin with an antibacterial ointment.
• Avoid needle sticks of any type into the limb (arm or leg) with lymphedema. This includes shots or blood tests.
• Use a thimble for sewing.
• Avoid testing bath or cooking water using the limb with lymphedema. There may be less feeling (touch, temperature, pain) in the affected arm or leg, and skin might burn in water that is too hot.
• Wear gloves when gardening and cooking.
• Wear sunscreen and shoes when outdoors.
• Avoid blocking the flow of fluids through the body.
• Do not carry handbags on the arm with lymphedema.
• Do not use a blood pressure cuff on the arm with lymphedema.
• Do not use elastic bandages or stockings with tight bands.
• Keep blood from pooling in the affected limb.
• Keep the limb with lymphedema raised higher than the heart when possible.
• Do not swing the limb quickly in circles or let the limb hang down. This makes blood and fluid collect in the lower part of the arm or leg.
• Do not apply heat to the limb.
• Studies have shown that carefully controlled exercise is safe for patients with lymphedema. is important to keep body fluids moving, especially through an affected limb or in areas where lymphedema may develop.
• Do not cross legs while sitting.
• Change sitting position at least every 30 minutes.
• Wear only loose jewellery and clothes without tight bands or elastic.

The goal of treatment is to control the swelling and other problems caused by lymphedema.

Treatment of lymphedema may include the following:

• Pressure garments
• Exercise
• Bandages
• Skin care

Damage to the lymph system cannot be repaired. Treatment is given to control the swelling caused by lymphedema and keep other problems from developing or getting worse. Physical (non-drug) therapies are the standard treatment. Treatment may be a combination of several of the physical methods.

Treatment of lymphedema may include the following:

Exercise
Both light exercise and aerobic exercise (physical activity that causes the heart and lungs to work harder) help the lymph vessels move lymph out of the affected limb and decrease swelling. Breast cancer survivors should begin with light upper-body exercise and increase it slowly.
Some studies with breast cancer survivors show that upper-body exercise is safe in women who have lymphedema or who are at risk for lymphedema. Weight-lifting that is slowly increased may keep lymphedema from getting worse. Exercise should start at a very low level, increase slowly over time. If exercise is stopped for a week or longer, it should be started again at a low level and increased slowly.

Pressure garments
Pressure garments are made of fabric that puts a controlled amount of pressure on different parts of the upper limb to help move fluid and keep it from building up. Some patients may need to have these garments custom-made for a correct fit. Wearing a pressure garment during exercise may help prevent more swelling in an affected limb. It is important to use pressure garments during air travel, because lymphedema can become worse at high altitudes. Pressure garments are also called compression sleeves and lymphedema sleeves or stockings.

Once the lymph fluid is moved out of a swollen limb, bandaging (wrapping) can help prevent the area from refilling with fluid. Bandages also increase the ability of the lymph vessels to move lymph along. Lymphedema that has not improved with other treatments is sometimes helped with bandaging.

Skin care
The goal of skin care is to prevent infection and to keep skin from drying and cracking. See skin care tips, in the Managing Lymphedema section.

Compression device: lymphapress
Compression devices are pumps connected to a sleeve that wraps around the arm or leg and applies pressure on and off in a sequential and graded manner ie more distally and less proximally. The sleeve is inflated and deflated on a timed cycle. This pumping action may help move fluid through lymph vessels and veins and keep fluid from building up in the arm or leg. The use of these devices should be supervised by a trained professional because too much pressure can damage lymph vessels near the surface of the skin.

Common post surgery sequelae felt as below….so don’t be worried

• You will feel some tightness in your chest and armpit after surgery. This is normal, and the tightness will decrease as you do your exercises.
• Many women have burning, tingling, numbness, or soreness on the back of the arm and/or on the chest wall. This is because the surgery can irritate some of your nerves. These feelings might increase a few days after surgery. But keep doing your exercises unless you notice unusual swelling or tenderness. (If this happens, let your doctor know about it right away.) 
• It may be helpful to do the exercises after a warm shower when muscles are warm and relaxed.
• Begin exercises the day after your surgery.
• Plan to take your pain medication 20 to 30 minutes before doing your exercises.
• Breathe deeply and often as you do each exercise.
• Do the exercises 3 times a day, every day, until you have regained full range of motion in your arm(s).
• Wear comfortable, loose clothing when doing the exercises.
• Do the exercises slowly until you feel a gentle stretch. Hold each stretch at the end of the motion and slowly count to 5. It’s normal to feel some pulling as you stretch the skin and muscles that have been shortened because of the surgery. Do not bounce or make any jerky movements when doing any of the exercises. You should not feel pain as you do them, only gentle stretching.

Stage 1: Exercises to do while you still have your drain(s) in place

1. Pump It Up

This exercise helps reduce swelling after surgery by using your muscles as a pump to improve the circulation in your affected arm (on the same side as your surgery).

1. Lie on your unaffected side with your affected arm straight out, resting on a pillow.
2. Slowly bend your elbow while making a fist at the same time.
3. Next, slowly straighten your elbow while opening your fist at the same time.
4. Repeat this pumping motion 15 to 25 times.

If you had surgery on both sides of your chest, repeat the exercise lying on the opposite side of your body.

2. Shoulder Circles

This exercise can be done sitting or standing. It’s a good warm-up exercise and can help relieve tension in your shoulders.

1. Lift both shoulders up toward your ears. Keep your chin tucked in slightly.
2. Gently rotate both shoulders forward, and then slowly down and back, making a circle.
3. Make 5 slow circles in one direction, then switch and make 5 slow circles in the opposite direction.

3. Arm Lifts

This exercise can be done sitting or standing. It helps improve movement in your shoulders.

1. Clasp your hands together in front of your chest. Point your elbows out. 
2. Slowly lift your arms upwards until you feel a gentle stretch, but no pain.
3. Hold for 5 to 10 seconds and then slowly return to the start position. 
4. Repeat 5 to 10 times.

4. Shoulder Blade Squeeze

This exercise can be done sitting (without resting your back on the chair) or standing. It helps to stretch your chest muscles.

1. Hold your arms at your side against your body with your elbows bent. 
2. Slowly bring your elbows straight backwards, while squeezing your shoulder blades together to feel a gentle stretch.
3. Hold this position for 5 to 10 seconds and then slowly return to the start position. 
4. Remember to keep breathing throughout the stretch. 
5. Repeat 5 to 10 times.

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Stage 2: Exercises to do after your drain(s) have been removed

You no longer need to do the previous exercises.

1. Wand Exercise

You will need a “wand” to do this exercise – try a broom handle, stick or cane.

1. Lie on your back with your knees bent. Hold the wand with both hands. Your hands should be as wide apart as your shoulders. 
2. Lift the wand over your head as far as you can until you feel a stretch. Your unaffected arm will help lift the wand higher.
3. Hold for 5 seconds, then gently lower your arms. 
4. Repeat 5 to 10 times.

To progress, repeat exercise with hands slightly wider than your hips or shoulders.

2. Winging It

This exercise helps stretch the front of your chest and shoulder.

1. Lie on your back with your knees bent. Touch your fingertips to your ears with your elbows pointed to the ceiling.
2. Move your elbows apart until you feel a gentle stretch, but no pain.
3. Hold this position for 5 to 10 seconds and then slowly return to the start position.
4. Remember to keep breathing throughout the stretch.
5. Repeat 5 to 10 times.

3. Snow Angel

This exercise helps to stretch the tight tissue in the armpit area and increases movement in your shoulders.

1. Lie on your back and extend your arms out at your sides. 
2. Move your arms up over your head, leading with your thumbs, eventually touching your fingers at the top.
3. Next, move your arms back down to your sides (as if you’re making an angel in the snow). 
4. Repeat 5 to 10 times.

4. Wall Climbing

This exercise helps increase movement in your shoulder. Try to reach a little higher on the wall each day. This exercise is done in 2 positions – A) facing the wall and B) with your affected side to the wall.

a. Facing the wall

1. Stand facing the wall.
2. Place the palm of your hand (of your affected arm) flat against the wall.
3. Slowly slide your hand up the wall as high as you can go until you feel a stretch, but no pain.
4. Hold for 5 to 10 seconds
5. Return to the start position.
6. Repeat 5 to 10 times.

If you had surgery on both sides of your chest, repeat this exercise with your other arm.

b. Side wall stretch

1. Stand with your affected side to the wall.
2. Place the palm of your hand flat against the wall.
3. Slowly slide your hand up the wall as high as you can go until you feel a stretch. Do not rotate your body toward the wall. Keep your body facing forward even if it means you can’t go up as high.
4. Hold for 5 to 10 seconds.
5. Return to the start position.
6. Repeat 5 to 10 times.

5. Side Bends

This exercise is more advanced and can be performed once a day when you feel ready.

1. Sit in a chair and clasp your hands together in your lap.
2. Slowly lift your arms over your head.
3. Bend at your waist to move your body to the right. Use your right hand to gently pull your left arm a little farther to the right. Keep yourself firmly planted on the chair.
4. Hold this position for 5 seconds and then slowly return to the start position.
5. Repeat this stretch to the left side, using your left hand to pull your right arm farther.
6. Repeat 5 to 10 times on each side.

Remember, it may take 6 to 8 weeks to regain full movement of your arm(s). If you continue to have difficulties regaining full movement in your arm(s) and shoulder(s) after this time, please ask your surgeon for a referral to physiotherapy and occupational therapy for follow-up.

Other activities:

It is safe to do light housework during the first 6 weeks after surgery. Do only short periods at a time and rest in between. You can start heavier activities after 6 weeks. Always let pain be your guide – a little discomfort is okay but more pain could mean you are doing too much.

On the day of surgery:

• Food after surgery: Patient may initially take clear liquids and preferably water 6 hrs after surgery i.e. after full recovery. If tolerated and patient desires, soft diet may be given as per patient’s wish. 

• Position after surgery: Better to remain 30- 45 degree head and back inclined up till full recovery.

• Post op treatment: Nurses will give the IV fluids as per instruction and sugars will be timely checked as ordered. Antibiotics,anti acidity  and pain medications will be given on day 1. 

• Patient’s previous medicines for comorbidities like blood pressure or diabetes etc can be resumed after the physician’s advice.

• Dressings: Dressing will be changed before discharge. It is advisable to actively learn and follow the dressing technique so relatives can do it at home as required.

Post anesthesia recovery symptomes:

You may feel drowsy and have minor side effects after your procedure or surgery with anesthesia. These side effects include:

• Sore throat            • Headache            • Muscle aches     • Dizziness off and on 

• Nausea                   • Vomiting (rarely) 

Some of these symptoms may be from the pain medicine you are taking. The side effects from anesthesia usually go away quickly in the hours after your procedure. Still, it may take several days for your body to recover from the stress of surgery and anesthesia.

Urinary retention (not being able to urinate) may occur after some procedures. If you are unable to urinate within 8 hours of going home after your procedure, or if your bladder feels painful and full, call the duty doctor or inform the nurse. In some patients, temporary insertion of a urinary catheter may be required.

At home care:

• Dressing: it is desirable to change the dressings at home daily. Patients can take showers, especially if plastic coated dressing is applied. After a week, soap and water can be applied to surgical site as well. Always dab it dry and clean the wound with propranolol [cutasept] or chlorhexidine based solution. Apply mupirocin ointment on the suture line.  Keep a thin layer of sterile gauze pieces dressing and secure it with micropore tape or use ready made tegaderm with pad dressings. 

• Wound inspection: it is important to note any collection, discharge, redness or pus from the wound. In doubtful circumstances readily click a photo and send across to the clinic number or doctor, else meet the doctor in the clinic.

• Patient will be given pain medications and antibiotics which can make the patient constipated. Increasing fluid, fiber and fruits in your diet may be helpful in avoiding this problem.  You may return to a normal diet immediately following surgery.  

• If you notice swelling in your hand or arm, it is expected at times post surgery: 

 Use 2 to 3 pillows to raise your arm higher than your heart. Do this a few times a day. You can raise your arm while you sit, lie on your back or lie on your side.

Raise your arm and slowly open and close your fist 10 times. This acts like a pump and helps drain fluid out of your arm. 

• Return to your daily activities as tolerated.

• You will return to the clinic a week following surgery. At this appointment, we will remove your dressings and you will receive pathology results from your pathologist. Further action plans can be sketched out after that.

• Suture removal is usually done after 2 weeks.
• NEVER EVER TO USE THE UPPER LIMB ON DISEASE SIDE FOR BLOOD PRESSURE MEASUREMENT, DRAWING BLOOD , INJECTIONS OR iv CANNULA 
• Drain care and removal: the tubes coming out from the operated area have a vacuumised box attached. It needs to be emptied daily at a fixed time so that the fluid in each 24 hrs can be measured. Date Wise charting of fluid output helps us in determining the time when the drain pipes can be safely removed. Details of drain care are given later separately. It is advisable to learn the emptying and recharging of drain while the nursing staff is doing.

When should I call  my doctor?

•  You have bleeding that soaks your dressing;
• Temperature taken by mouth between 38-38.2° C (100.4-100.8°F) for one hour or more, or a temperature that is 38.3°C (100.9°F) or above; or  temperature taken under the arm between 37.5-37.7° C (99.5-99.9°F) for one hour or more, or a temperature that is 37.8°C (100° F) or above;
•  If you have chills;
• You have any sign of infection: redness, increased pain, swelling, foul-smelling drainage, or increase in the amount of drainage from your wound;
• You notice an increasing fullness of your skin where your drain site was;
• You have concerns that cannot wait until your follow- up visit.

In case of severe emergency, reach out to the nearest specialist or hospital if your doctor is not available or reachable.