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.

by DR HITENDRA PATIL

Consultant Surgical oncologist & Director, Suyog cancer clinics, Thane

Exercises after the surgery

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).

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.

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.

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.

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

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 Rolling

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