"It's the Day of Surgery and I've Got My Period, Now What?"...And Other Questions You Were Too Afraid to Ask Your Surgeon

By Dr Donald Angstetra, Dr Graham Tronc, Dr Peta Wright, Lauren Iacobucci, and Dannielle Stewart

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So you’re about to have surgery. Whether it’s your first time or you’re a veteran of the operating theatre, you’re bound to have questions, and you might even think some of those questions are downright odd. Never fear, QENDO have assembled a panel of specialist gynaecologists and perioperative nurses to answer your surgery questions, from the mundane to the strange. As always, remember to consult YOUR surgeon for advice and don’t be afraid to ask questions of the person who will performing your surgery.

Meet the Panel

Dr Donald Angstetra - MBBS, FRACOG

Gold Coast obstetrician and gynaecologist Dr Angstetra is an experienced excision specialist with a keen interest in endometriosis as well as an exceptional obstetrician able to handle high risk pregnancy.

Dr Graham Tronc - MBBS, FRACOG

Dr Tronc is a Brisbane based obstetrician and gynaecologist with a special interest in endometriosis and adenomyosis, with extensive experience in the surgical diagnosis and treatment of both conditions. He is also a fertility specialist and talented obstetrician.

Dr Peta Wright

Dr Wright is a Brisbane gynaecologist with Eve Health, with a special interest in paediatric and adolescent gynaecology. Dr Wright is known for her holistic approach to women’s health and is passionate about helping those with pelvic and pain endometriosis, as well as empowering all women to harness what she calls “the magic of the menstrual cycle”.

Lauren Iacobucci, RN - BN/Grad.Dip.Nurs (Anaesthetics & Recovery)

Lauren is a registered nurse with a speciality in anaesthetics and recovery. She is with patients across their anaesthetic journey in surgery, from pre-op to post-op, and has a great deal of experience in caring for patients from a range of surgical specialties, including gynaecology. Lauren can help answer all things anaesthetics and recovery, and what you can expect from your anaesthetic experience.

Dannielle Stewart, RN - BA/MNursSt

Dannielle is a registered nurse with experience both inside and outside the operating theatre. She has worked in both inpatient surgical wards and outpatient surgical clinics in Brisbane, across a range of specialties, and currently works in the UK as a scrub nurse at a university hospital. Dannielle can help answer your post op questions, as well as the burning curiosity so many of us have - what the heck happens while I’m asleep?

It’s the day of surgery and I’ve got my period, now what?

Dr Peta Wright clears this one up succinctly, “having your period doesn’t matter”.

It can be awkward, sure, but realistically it won’t affect your procedure and your surgeon is plenty used to seeing blood! Scrub nurse Dannielle adds, “let your admitting nurse know when they get you changed, they can provide you with sanitary products and pass the information on to recovery staff to preserve your dignity post op, you’ll have enough to worry about without stressing about whether your pad is still there! A note on tampons: your nurses will likely ask you to remove a tampon and opt for a pad instead to reduce the risk of infection - anaesthetic can wreak havoc with focus and memory, albeit temporarily, and you may forget about that tampon post op.”

Bowel prep…do I really have to?

This one is down to the personal preference of your surgeon, and the type of surgery being performed. But it’s not just to torture you, there’s a very good reason for it. On the subject of bowel prep, Dr Tronc says, “Personally I suggest a bowel prep for all of my patients’ having laparoscopic surgery for suspected endometriosis or endometriosis that would also have caused adhesions. The use of bowel prep by other surgeons will vary on their experiences and the type of patients they see in their practice.”.

“I use bowel preps routinely for two reasons. Firstly, a full constipated or slowly moving bowel, simply gets in the way of what I am trying to do in the pelvis. The last thing I want to have to do is constantly have to move the bowel out of the way, especially when I am dealing with difficult endometriosis disease, often associated with adhesions, deep in the pelvis, where the ureter, (the tube between the kidney and the bladder), and major blood vessels sit”.

“The second reason I personally use a bowel prep, is that when I’m dissecting large areas of peritoneum (skin) off around and over the rectum, I feel more comfortable if the bowel is empty. In the very unlikely event that a hole is made in the bowel, much less faecal matter is likely to leak into the pelvis. Opinion varies, and there are no hard and fast rules. Similarly, some surgeons use a full bowel prep, others use an enema”.

“If a bowel prep is used, the Anaesthetist is always made aware of this, and will usually give the patient an extra litre or so of intravenous fluid to avoid the complication of dehydration. Be aware however that the combination of a bowel prep and fasting for 12 hours and not eating much for 24-36 hours after the operation, means that it is quite common for patients who normally move their bowels daily, not to go for three days or so. Movicol sachets can work well here. Try the chocolate, it tastes better”.

Special shower gel, no make up or deodorant and weird stockings. Please explain?

“Patients often think they’re doing me a favour by wearing deodorant before theatre, but there’s a reason we want you bare faced and using only the surgical skin prep we’ve requested,” Dannielle explains. “The skin prep helps to reduce the amount of microbes on your skin before surgery, that funky smell is usually chlorhexidine - the same disinfectant I wash my hands with before I scrub in for your procedure. We all have bacteria on our skin, that’s normal, but surgery means creating a pathway for that bacteria to enter your body and blood, and so that’s why we’re serious about what’s called asepsis. Once you’re asleep the surgeon and scrub nurse will complete a 3-5 minute surgical scrub and don a sterile gown and gloves, only they can touch the surgical instruments and other sterile equipment known as the sterile field - reducing greatly the amount of microbes that can cause infection. It’s impossible to get rid of every single microbe, that’s why we wear gown, gloves and mask, and why we wipe the skin to be cut with an antiseptic solution. Sometimes you’ll be given antibiotics too - but that’s down to the personal preference of the surgeon or anaesthetist, and the type of surgery you’re having.”

“On deodorant and makeup - we need to make sure you’re not introducing more bacteria onto your skin (that you so painstakingly cleaned with your prep!), and we also want to make sure no products containing alcohol are on your skin that could prove a safety hazard or obstruction to certain equipment like diathermy or monitoring devices. Once surgery is over you can have your favourite products back, I promise!”

“As for those fetching white stockings we make you wear? It’s not just to make you look the height of fashion, it’s to prevent blood clots (also known as venous thromboembolism). The stockings encourage blood to be returned to the heart from your legs, avoiding pooling which increases your risk of clots. You can keep wearing them at home post op while you’re taking it easy too. Save them for your next long haul flight too!”

I’m actually starving right now, why do I have to fast?

Anaesthetic nurse Lauren says: “When booked in for surgery, you’ll be instructed to fast from both food and drink prior to your surgery. Most commonly you’ll be told to fast from midnight for a morning surgery and from 7am for an afternoon procedure. Current guidelines state minimum fasting should be 6 hours for food and at least 2 hours for clear fluid, but it does depend on your specific hospital and doctor’s guidelines so make sure you follow these. Contrary to popular belief, we don’t get you to fast because we’re cruel. There are actual medical and safety reasons why you must fast prior to your surgery no matter how hungry you are. Being put under a general anaesthetic or sedation suppresses your natural ability to protect your airway, putting a patient at risk of regurgitating stomach contents into the lungs which causes a whole variety of issues. Fasting minimises the risk of aspiration and is therefore very important.”

I hate hospitals…and needles, how do I stay calm on surgery day?

Lauren explains: “Everyone gets nervous about having surgery. It is a completely normal emotion. And as surprising as it may be, no one loves needles. It’s important to look after and be gentle with yourself in the lead up to your surgery. Mindfulness and meditation can really help so maybe try and download an app you can listen to while waiting for your surgery. You can also bring a support person with you to help relax you, keep you calm and take your mind off things. When you arrive at the hospital, don’t be afraid to let the nurses know how nervous you are. We understand that unlike the medical staff, you’re not used to spending your time in hospitals so we expect patients to be nervous and do our best to comfort you. Another little trick is that when the cannula is being put in, focus on wriggling your toes to take your mind off it. As an anaesthetic nurse, I also make sure I’m available to offer a hand to hold. As soon as the anaesthetist starts to give you the medication, all your cares will fade away.”

The anaesthetic doctors on Grey’s Anatomy seem to read a lot of magazines, what do they actually do?

Miranda Bailey may have accused Ben Warren of being too busy doing his sudoku to pay attention to the patient in the table, but Lauren explains this is far from reality: “Who buys magazines anymore?! These days magazines have been replaced with iPads! Anaesthetists have a hugely important role in your surgery experience. They’ve undergone 10 years of medical training to do more than read a magazine or play on an iPad. They’re responsible for making sure you are safe while you are asleep including delivering medication and monitoring your airway, breathing, blood pressure, heart rate and ensuring you remain stable and safe during surgery. Seems simple doesn’t it? You may have also noticed on Grey’s Anatomy they have music playing in theatre- this actually is true depending on your surgeon and anaesthetist.”

Dannielle confirms: “a good playlist helps keep the team in good spirits sometimes! But my first move as a scout nurse is to switch it off if I see my surgeons hitting a rough patch or there is a lot of requests flying about the room. We’re here to do our jobs to the best of our ability. For any patients having a local anaesthetic (where you’re not asleep), we often play music to keep the patient at ease and distract them from the not so fun sounds of theatre.”

Tell me straight, how many people are going to see me naked?

“Upholding patient privacy and dignity is our priority alongside safety in theatre,” says scrub nurse Dannielle. “Once you’re anaesthetised the theatre team, which includes doctors, nurses, nursing assistants and porters will position you for the surgery. Sometimes you’ll be asleep in the anaesthetic room and the team will slide you across to the table using a special board called a pat slide and a slippery sheet that allows you to be safely transferred from your bed to the table. Other times you’ll be anaesthetised on the operating table and, once asleep, the team will position you appropriately. A laparoscopy only requires your belly to be exposed, so you won’t be naked on the table! Theatre can be very cold too, and so we keep you covered and warm where possible. You’ll be draped with sterile drapes by the surgeon and scrub nurse so that only your belly is showing - this is for infection control purposes, as well as to preserve both warmth and dignity. Special care is taken with positioning to ensure you don’t develop any pressure areas or bruises, and sometimes you’ll have a device called a Bair Hugger which blows warm air on you to keep you nice and toasty during your op.”

“If you’re having a hysteroscopy or IUD insertion alongside your laparoscopy, your surgical team will position your legs in stirrups, which are much more padded and supportive than the kind in your local doctor’s office, so that the surgeon can gain access to the cervix. You’ll still be draped though, so again, you won’t just be naked for anyone to see. Yes, there’ll be a point where you need to lose those paper undies the nurses gave you and often your gown too - but you’ll be covered during surgery and a fresh gown will be placed on you before you wake up. Access to theatre is restricted too, so not just anyone can wander in, thus only essential personnel will be present during your surgery. Your anaesthetic team in particular will be concerned about keeping you warm and covered, ensuring your privacy and dignity is preserved throughout surgery.”

What actually happens while I’m asleep? Are the surgeons really talking about their relationship problems like Derek and Meredith?

“Now that I’m a nurse, I’m not sure how Derek Shepherd managed to do brain surgery and talk about his Meredith Grey problems simultaneously. Surgeons don’t often like a lot of chat in surgery, though it depends on the doctor,” says Dannielle. “They have a highly technical job to do and it requires a lot of concentration, we don’t often have time to chat about our weekend! Surgeons mostly talk about the procedure, often they’re teaching more junior doctors a surgical technique or consulting with the scrub nurse or assistant surgeon about what equipment or instruments they would like. The team’s focus will be on you, don’t worry!”

How long will my surgery take?

Dr Donald Angstetra says, “It depends on the complexity of the surgery and how much endometriosis the gynaecologist has to remove. The procedure can last anywhere from 45 minutes to 6 hours or more. Surgery for endometriosis can be very complex and It will take longer if a condition required bowel resection or urological procedure”.

Your surgeon will usually have an idea of how long your procedure will take based on what they know, but that can change once they actually begin the procedure, especially for a diagnostic laparoscopy where the amount of disease is often completely unknown.

My doctor and I talked about possible complications, what’s the chances they’ll actually happen?

Deep breath, that consent form can be overwhelming, but you’re in good hands. Dr Angstetra says, “Laparoscopy surgery for endometriosis is relatively safe, but with all surgical procedures, there are risks involved. Most complications are minor. However, rare and serious complications may occur.”

“Large studies show that the rate of all complications in laparoscopy is less than 1% (1 in 100), with the rate of majorcomplications less than 0.5% (1 in 200) - RANZCOG Laparoscopy patient information. Common complications include pain, nausea and vomiting, internal bleeding, wound infection (1:20), urinary infection (1:20), infection of the uterus and vaginal bleeding. Rare complications include Injury to major blood vessels (1:500) which may lead to massive blood loss and blood transfusion; damage to organs such as the bowel (1:250), bladder (1:200) and ureter. Risk of injury increases with the severity of endometriosis. These complications may require immediate treatment. They can be serious and may require more extensive surgery at a later time, development of fistula (an abnormal connecting passage between two internal organs). Other uncommon complications include blood clots in your legs or lungs, surgical emphysema, where the carbon dioxide gas becomes trapped in your skin, and hernia at one of the incision sites”.

Dr Angstetra stresses that these complications are uncommon and that a skilled surgeon will know immediately how to cope with any complications, or potential complications. Dannielle adds, “theatre staff brief before the surgical list begins to ensure everyone understands the potential complications facing each patient, and what each staff member must do in the event of an emergency - your team is well equipped to deal with changes in your condition and you can always ask questions of us before surgery”.

Should I stay overnight or do day surgery? What’s the difference?

Most people run far away from hospital if they can help it, but is it better to stay sometimes? Dr Peta Wright says it really depends on the type of surgery performed. A diagnostic surgery, or one where only mild endometriosis is found, is usually a day surgery because that patient will usually have a faster recovery. Whereas a large excision, or an excision involving the bowel warrants an overnight stay.

Dr Tronc also suggests that the more complex the surgery, the more likely the patient may need an overnight stay, adding that other factors are also at play, for example the way the patient reacts to the anaesthetic, their level of dehydration, or nausea and vomiting.

Scrub nurse Dannielle says, “other considerations may be hospital based, for example if your procedure is delayed or at the end of the surgical list (resulting in a later finish and recovery room time), you may not be ready to discharge until the next morning”. She adds, “patients are unable to be alone for 24 hours after an anaesthetic, and so if there is no one appropriate at home to look after you, you’ll need to stay you’re fully recovered from your anaesthesia”.

What’s the deal with the pain in my shoulder, should I be worried?

It’s weird, annoying, and can be painful, but it’s nothing to panic about. Dr Tronc explains the origin of “gas pain” or “shoulder tip pain”: “Carbon dioxide (CO2) gas is instilled into the perineal cavity, before the scope is inserted, to create a safe “window” to operate through. Most of the gas is released at the end of the operation, but some always stays in there, trapped between loops of bowel. This gas (and sometimes irrigation fluid used to try to prevent adhesions) ,irritates the diaphragm, and an odd nerve communication that exists between the diaphragm and the shoulder, causes what is called “referred pain” in the shoulder and sometimes the neck. Not everyone gets this of course, but most do. It lasts two to three to four days!”

Dr Donald Angstetra adds, “The pain can occur during deep breaths. This type of pain can be quite uncomfortable and may last several days. It will eventually resolve on its own but can be aided by walking and moving around. Massage, cold/heat pack and simple analgesia (such as ibuprofen or paracetamol) often bring the quickest relief”.

My boss won’t stop asking when I can go back to work, how long should I really have off?

While your postoperative instructions (which you should refer to in the first instance and then speak with your surgeon if you have concerns) may list anything from 2-3 days to 7 days, our panel explains that recovery is different for everyone. Dr Peta Wright recommends setting aside at least a week to recover and also let family, friends, and work know you will have to to take extra care of yourself over the coming weeks so that you don’t feel too overwhelmed.

Dr Graham Tronc explains, “how long you may need to take off work, will depend on your job (including how many children you have – the more children you have, the more your family needs to pitch in). If your job is physical, such as mining, a teacher, nurse, athlete or someone who’s work requires you to walk long distances, (eg a law clerk who runs around the city with files,) then  you will need more time off. Time off will be also dictated by your age, other medical conditions, how you react to anaesthetic (most patients are actually fine), but MOST importantly, just how much surgical work was performed by your Endometriosis specialist. Patients who have had an extensive resection of endometriosis, from the skin (peritoneum) on, eg both pelvic side walls, including over the ureters, perhaps with dissection of disease from the bladder and rectum, will of course be in more pain than someone where no endometriosis is found and perhaps the cause of the problem has been adenomyosis”.

What’s the most important thing I can do to help my recovery?

Dr Peta Wright says, “try to get moving gently as soon as possible, muscles love to move! A healthy diet with lots of fibre and water will aid gut recovery and overall wellbeing, as will getting off opioids as soon as possible. Practice self care and focus on what life after surgery looks like - ie getting back to living a full and happy life. Understand surgery doesn’t usually take away all your pain or cure endo and recovery may involve other things like physio, a healthy diet and exercise program and mindfulness, as well as other hormones and medications in some instances”.

What if they don’t find anything?

Don’t panic. It’s a concern so many of us have, but laparoscopy is not the whole story! Dr Graham Tronc says, “there is always a cause for abnormal bleeding and severe pain, we just have to listen carefully and look hard”. Dr Tronc explains that the diagnosis of adenomyosis is often suspected at laparoscopy, but may require either ultrasound or MRI (by a skilled and experienced professional) to confirm the diagnosis. In most cases, if you are having a laparoscopy by a skilled excision specialist, they have taken a thorough history and that history is highly suggestive of either endometriosis or adenomyosis (or both!) - chances are something will be found during your surgery. If that’s not the case, it’s not the end of the road, just another step on your journey to diagnosis.