Sunday, January 3, 2016

What about activity restrictions after surgery?

Although, uncommon, bleeding after surgery is the most common potential post-operative complication. To minimize the chances of this occurring, patients are advised to be as minimally active after surgery as possible. This includes activity restrictions such as:
No bending or heavy lifting
No rigorous exercise or exertion
Do not make important plans in the days immediately following your surgery

The above instructions appear on the website of a medical school department. The operation in question is

A. Cholecystectomy
B. Partial mastectomy
C. Inguinal hernia repair
D. All of the above
E. None of the above

Answer: E. None of the above. While all three of the operations mentioned could have been the subject of these activity restrictions, they were taken from a dermatology service's description of the aftercare of Mohs surgery, which is a way of exercising skin cancers—not exactly major surgery.

This topic was suggested to me by a Twitter follower.

I told him that as far as I knew, there is no evidence basis for any of the activity restrictions we tell patients.

When I was a resident in the early 1970s, we kept patients who underwent inguinal herniorrhaphy in bed for no fewer than five days, and nephrectomy patients were bedbound for a week.

For the former, the theory was that early activity might disrupt the repair—implying that many repairs were tenuous in those days. Regarding nephrectomy, the prevailing wisdom was that the tie or ties on the renal vein could be dislodged by increased pressure in the inferior vena cava from something as trivial as a Valsalva maneuver. Following this logic, we should have prevented nephrectomy patients from coughing or having bowel movements too.

Since then, progress has been made. Hernia patients are discharged on the day of surgery, and nephrectomies are not kept in bed.

What is the definition of "heavy lifting"? It is usually described as lifting more than 10 lbs. Where did that come from? Other than 10 being a nice round number, I can't think of another reason.

A far-from-exhaustive literature search revealed no evidence-based studies and nothing at all pertaining to general surgery.

A 2008 opinion paper suggested that cardiac surgery patients who have excessive limitations on their activities might suffer excessive anxiety and depression leading to poor outcomes. They recommended that patients be given "personalized activity guidelines developed by an exercise specialist to help them resume their presurgical lives."

Activity restrictions after gynecologic surgery are also not evidence-based. A review from the University of Utah found no studies relating postoperative activity and surgical success. A previous survey had found "Depending on the surgery, 88-99% of surgeons restricted lifting for mean of 5–7 weeks (range 1–26 weeks and up to 'forever' [?] after vaginal hysterectomy with vaginal repairs)."

In 2011, an expert panel said patients undergoing laparoscopic supracervical hysterectomy should avoid lifting more than 10 kg, bicycle riding, and vacuum cleaning [?] for two weeks.

At the other extreme is the story of Ryan Callahan, a forward for the Tampa Bay Lightning of the National Hockey League. Last May, he began practicing three days after a laparoscopic appendectomy and played in a playoff game two days later.

To put it mildly, the topic of postoperative activity restrictions is long overdue for prospective study.


daco said...

As a rule, I tell my laparoscopic (chole and appy) and open appy patients no heavy lifting (heavier than a gallon jug of milk) for 1-2 weeks, 3-4 weeks for hernia and laparotomy patients. However, I always tell them that the best indicator of activity level is comfort level. ie, if it doesn't hurt, they aren't hurting anything. If it does hurt or they get worn out, then back off. No real scientific evidence, but it seems to work.

People have a wide range of how fast they recover from surgery, and simply going by their own body's feedback seems to be the best advice in my experience. Of course, I have to caution them that they have to be honest with themselves. I love to tell kids (after appy or hernia repair) how much smarter they are than adults. Kids will stop doing something if it hurts. You have to be an adult to be dumb enough to keep doing something that hurts. :)

Anonymous said...

Great posting!
We showed, in a rather limited prospective randomized trial, that physical exercise
following cystectomy is of benefit for the patients.

Please see link:
Best regards

Amir Sherif
Urology section
UmeƄ University Hospital

Anonymous said...

Alert Artiger, I gotta hear a comment on this.

I totally agree. I had my first abdominal surgery and it took 2 weeks just to do basic stuff. My second I was ready to go after a few days. My 3rd one (different surgery than the first 2), I was ready to go in 5-6 days. The 4th, simple lap choly, I couldn't really get a clue until a day or so after and my parents were afraid for me to leave the hospital until 48 hours after. Anesthesia issues. Once that resolved, I was ok to hit the saddle in a week, but restrained until two weeks and then the doctor said three. I asked him what he was smoking. :)

Skeptical Scalpel said...

Daco, I agree that pain is a good barometer for limiting activity.

Amir, nice article. More activity is better.

Anon, everyone recovers at a different pace and each operation is different too. One activity regimen does not fit everyone.

Anonymous said...

You should take a look at this study. They measured intragastric and bladder pressures while people were coughing, retching and lifting weights. Coughing and retching increased pressure much more than lifting weights.

The mean bladder pressure while bench pressing 114 lbs was 5 mm Hg, comprared to coughing 37 and vomiting 81. But I guess its a lot easier to tell a patient not to bench press 114 lbs for 4 weeks than it is to tell them not to cough for 4 weeks.

Skeptical Scalpel said...

Anon, that is really interesting. Can you post a link to the study or cite it please?

Anonymous said...

Skeptical Scalpel said...

Thanks for the quick response. I will get the full text and read it.

Ro Mg said...

Interesting article. I was a resident in the 80s, and there was no bedrest for hernia patients. I think your hospital may be have over conservative. I did scrub with a very old scrub nurse back then who was a nursing student back in the 1930s. She said hernia repair patients were at strict bedrest for a week, and her job was to spoon feed the patients, because it was feared lifting the head off the pillow to eat could rip the repair.....times certainly have changed.

Olympicdc said...

Great post. Thank you. Unfortunately, I have too much experience as a surgical patient: 2 inguinal herniorrhaphies, Heller myotomy, multiple pneumatic dilations, and esophagectomy. To say that the post-surgical activity restrictions were inconsistent is an understatement. I am also a competitive weightlifter which you would think would factor into the recommendations - nope. How you lift (and even how your think about the lift), how you perform any activity, will completely change the forces imparted on the body. This is even true for coughing, sneezing, and any other valsalva maneuver. Learning how to breathe is the key. Is the surgeon ever involved in these recommendations? Yes, they will make recommendations, but have never been involved in my recovery process. Lucky for me, my specialty is physical rehabilitation, so I wrote my own recovery program (with the help of many others). I cannot tell you how important this is for OPTIMAL recovery. If this program is not discussed with the patient and written pre-surgery, the patient is already behind. I have treated so many patients for whom no guidance whatsoever was given and this is not only disappointing, but unacceptable. For the surgeons out there, if you are interested in learning how to significantly improve your outcomes, I would love to discuss. I have heard, “how come he/she never told me about that” too many times.

Skeptical Scalpel said...

Ro, things changed in late 70s. No more drains or NG tubes in cholecystectomies. Breast biopsies went home same day, and much more.

Olympic, you are correct. I hadn't thought about it before, but this is an area that needs a lot of improvement.

Anonymous said...

I am a physician, and I have three inguinal hernia repairs.
The first was over 30 years ago. I was in the hospital for a couple of days and severely activity restricted, and the first week after surgery was the worst of the three repairs.
Then that hernia recurred in 1990's and the instructions included early mobilization on the day of surgery, and increasing walking as tolerated starting on the day of surgery, and the first week of surgery was much more comfortable.
Then I had another hernia on the other side, where the surgeon wanted a fair amount of walking on the day of surgery and vigorous walking starting the day after surgery, and again the first week after surgery was much more comfortable than when no activity was recommended many years ago.
Facial skin cancer surgery instructions to prevent post operative bleeding may not be all that analagous to surgery of specialized areas (e.g., inguinal hernia) where immediate stretching of tissue may of significant benefit.

Skeptical Scalpel said...

Thanks for your input. Walking after hernia surgery may have started at the Shouldice Clinic in Canada. I visited there in 1980 and was impressed that postop patients were walking around. The rest of the world gradually adopted the policy.

Anonymous said...

Dear Skeptical Scalpel,

Thank you for the post! I learned something new today about Valsalva and inguinal hernias (just a hobbyist hoping to be an RN in a few years). Muchos Gracias!!!

Anonymous said...

A case study supporting your point:

Jeff Farrell qualified for the 1960 US Olympic Swimming Team - 6 days after an emergency appendectomy.,343451&hl=en

I was a senior at Wichita High School East when this happened and graduated in 1961, four years after Jeff Farrell. Not a swimmer or even a varsity runner in cross country or track, I am forever grateful for my time with "Timmie" and believe Jeff Farrell's swimming training under Coach Timmons (Wichita Swim Club and 1 year at Wichita East)fueled his determination through his life ever after.

More about Jeff Farrell:

And about "Timmie":

Identified by Robert Gates as " a particular person outside his family who had a lasting influence on him."

Skeptical Scalpel said...

Anon, thanks for the links to the story of Jeff Farrell. Don't forget, his operation was an open appendectomy with a medium to large incision. That's the way it was done back in the day.

Libby said...

yes each person & surgery creates a new situation.

When I was a student nurse in 1986 I had a patient who I was suppose to give a shot of morphine the morning after her hernia operation. She was a jazzerize instructor & no kidding, I actually had to walk really fast to catch up to her on her "walk" down the hallway!

Skeptical Scalpel said...

Fit people tend to recover faster than those who aren't fit.

@erikneves said...

« 40 days prior to the 1964 Summer Olympics in Tokyo, during a training run near Addis Ababa, Abebe Bikila started to feel pain. Unaware of the cause of the pain, he attempted to overcome this pain but collapsed. He was taken to the hospital where he was diagnosed with acute appendicitis. He was operated on and shortly thereafter and even during his recovery period he started jogging in the hospital courtyard at night. »

Skeptical Scalpel said...

Erik, great story. I had not heard about it before. Thanks.

Bill Parker said...

A study following gynecologic surgery:

Methods: Thirty women of wide age and weight ranges who were not undergoing treatment for pelvic floor disorders performed 3 repetitions of various activities while intra-abdominal pressures (baseline and maximal) were approximated via microtip rectal catheters.

RESULTS: Median peak abdominal pressures ranged from 48 (lifting 8 lb from a counter) to 150 (lifting 35 lb from the floor), with much variation. Many activities did not raise the intra-abdominal pressure more than simply getting out of a chair, including lifting 8, 13, and 20 lb from a counter, lifting 8 or 13 lb from the floor, climbing stairs, walking briskly, or doing abdominal crunches. Body mass index and abdominal circumference each correlated positively with peak, but not net, pressures.

CONCLUSION: Some activities commonly restricted postoperatively have no greater effect on intra-abdominal pressures than unavoidable activities like rising from a chair. How lifting is done impacts intra-abdominal pressure. Many current postoperative guidelines are needlessly restrictive.

Weir LF, et. al. Postoperative activity restrictions: any evidence? Obstet Gynecol. 2006;107:305-9.

Skeptical Scalpel said...

Bill, thanks for the reference. It is similar to the one posted by anonymous on 1/4/16. Amazing that studies like this have received no mentions and have had no effect on the way postop patients are managed.

Don said...

I was in the recovery room after a minor procedure when the guy in the next bed was asked by a nurse if he had urinated yet. He answered "No". The nurse looked concerned, until he went on: "the doctor told me to avoid heavy lifting" The whole room erupted in laughter.

Skeptical Scalpel said...

Don, I laughed out loud at that one. Thanks.

GH said...

Amazing post!

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