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Colectomy (ACS)

Colectomy (ACS)

AMERICAN COLLEGE OF • DIVISION OF EDUCATION Surgical Removal of the Colon

Digestive System The Condition Possible surgical risks include temporary A colectomy is the removal of a section problems with the intestine that may of the (colon) or bowel. require a ; leakage from the colon Transverse This operation is done to treat diseases into the ; lung problems including Colon of the bowel, including Crohn’s disease pneumonia; of the wound, and ulcerative ; and colon . blood, or ; blood clots in the veins or lung; ; fi stula; or death. Common Symptoms Risk of not having an operation—Your Ascending Descending ● Symptoms may include diarrhea, symptoms may continue or worsen, and Colon Colon , abdominal cramps, your disease or cancer may spread. nausea, fever, chills, weakness, or loss of appetite and/or weight loss, or bleeding. ● There may be no symptoms. This is Expectations why screening is essential.* Before your operation— Evaluation Anus may include a , blood work, urinalysis, chest X-ray, or CAT Scan (CT) Treatment Options of the abdomen.1 Your and Surgical Procedure provider will discuss your Patient Education health history, home medications, and This educational information is Open colectomy—An incision is made postoperative control options. to help you be better informed in the abdomen and the section of the diseased colon is removed. The two The day of your operation—You will about your operation and not eat for 4 hours but may drink clear empower you with the skills and divided ends of the colon are sutured (sewn) or stapled together in an liquids up to 2 hours before the operation. knowledge needed to actively Medication to clean out your intestines participate in your care. . If the colon cannot be sewn back together, it is brought up through and an antibiotic may be started the day the abdomen to form a . before. Most often you will take your Keeping You normal medication with a sip of water. Laparoscopic colectomy—A light, Informed camera, and instruments are inserted Your recovery—The average length through small holes in the abdomen to of stay is 3 to 4 days for a laparoscopic Information that will help you 2 remove the diseased colon or tumor. or open colectomy. The time from further understand your operation your fi rst bowel movement to eating and your role in healing. Nonsurgical Procedure normally is also about 3 to 4 days. Education is provided on: Some diseases of the colon are treated Call your surgeon if you have continued with antibiotics, steroids, or drugs nausea, vomiting, leakage from the wound, Colectomy Overview ...... 1 that aff ect the immune system. blood in the stool, severe pain, Condition, Symptoms, Tests ...... 2 cramping, chills, or a high fever (over 101°F Treatment Options…...... 3 or 38.3°C), odor or increased drainage Risks of These Procedures ...... 4 Benefits and Risks from your incision, a swollen abdomen Preparation or no bowel movements for 3 days. and Expectations ...... 5 of Your Operation Your Recovery B e n e fi t s — Removal of diseased or and Discharge ...... 6 cancerous sections of the intestine Pain Control...... 7 will relieve your symptoms and can reduce your risk of dying from cancer. Glossary/References ...... 8

*See ACS colonoscopy resource: facs.org/~/media/ les/education/patient%20ed/colonoscopy.ashx

This first page is an overview. For more detailed information, review the entire document.

AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation The Condition, Symptoms, Colectomy and Diagnostic Tests SAMPLE

Sigmoid Colectomy (Sigmoidectomy) Segmental Resection Part or all of the sigmoid colon is removed. One or more short segments of the colon are removed. The is then reconnected to the rectum. The remaining ends of the colon are reconnected.

The Condition The Procedure Symptoms There are diff erent types of conditions and There are diff erent procedures to treat The most common symptoms are: diseases that may aff ect the intestines: diseases of the bowel and intestines: ● Diarrhea, constipation, abdominal ● Infl ammatory bowel diseases include ● A colectomy is an operation to cramps, nausea, loss of and Crohn’s disease. remove a part of the intestine (bowel) appetite, or weight loss that is diseased. The name of the Fever, chills, or weakness ● Ulcerative colitis presents as ulcers ● (tiny open sores) in the inner layer procedure depends on what section of the colon and includes bloody of the intestine is removed. diarrhea and .3 ● Right hemicolectomy is the removal Common Tests of the ascending (right) colon. ● Crohn’s disease is the infl ammation of History and Physical Exam the entire lining of the digestive tract, ● Left hemicolectomy is the removal You will be given a physical exam and 4 with 15% of cases in the colon only. of the descending (left) colon. asked about you and your family’s This usually presents with continual Sigmoidectomy is the removal of complete medical history, including 5 ● diarrhea and abdominal pain. the lower part of the colon which symptoms, pain, and stomach problems. ● is an infl ammation or is connected to the rectum. infection of small, bulging pouches Additional Tests (see Glossary) ● Low anterior resection is the removal (diverticula) located in the colon. of the upper part of the rectum. Other tests may include: Colorectal is any growth on ● ● Segmental resection is the removal ● Blood tests the lining of the colon or rectum. of only a short piece of the colon. ● Urinalysis ● is a malignant ● Abdominal perineal resection is ● Digital rectal exam (cancerous) tumor in the colon or rectum. the removal of the sigmoid colon, rectum and anus and construction ● Abdominal X-ray Parts of the Colon of a permanent colostomy. ● Abdominal ultrasound Transverse ● Total colectomy is when the entire ● Colonoscopy Colon colon is removed and the small ● Computerized tomography (CT) scan intestine is connected to the rectum. ● Electrocardiogram (ECG)—for patients ● Total is the removal of over 45 or if high risk of heart problems the rectum and all or part of the colon. Ascending Descending Colon Colon

Sigmoid Colon

2 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Surgical and Colectomy Nonsurgical Treatment

Stoma Interior Keeping You Laparoscopic Repair Informed

Conversion

Your surgeon may need to convert from a laparoscopic colectomy to an open colectomy. This may be needed due to:9

Abdominal • Adhesions from Stoma Surface prior • Bleeding • • Inability to see important structures • Presence of a large tumor • Inability to complete the operation Patients whose operations were converted from abdomen is then inflated with carbon dioxide, laparoscopic to an Surgical Treatment which allows the surgeon to see the intestines open colectomy did not have adverse short- or A colectomy can be done by open or and organs clearly. Small instruments inserted long-term effects.9 In a laparoscopic repair. The type of operation through the ports are used to remove diseased large study with over will depend on the condition, size of the colon or a tumor. If the colon cannot be sewn 41,585 patients having a diseased area or tumor, and location. back together, the ends of the intestine are colectomy, Your health, age, anesthesia risk, and the joined together or a stoma is created. was successfully surgeon’s expertise are also important. Benefits of Laparoscopic Colectomy performed while Open Colectomy Benefits include less scarring, earlier 2,508 (5.8%) patients return of colon function, less pain, and required conversion to An incision is made in the abdomen and the 10 6 an open procedure. diseased section of the colon is removed. shorter hospital stays. There has been no The healthy parts of the colon are then difference between laparoscopic and open 7 stitched or stapled together (anastomosis). colectomy for 5-year cancer survival rates. If the colon cannot be sutured back New studies using enhanced recovery together, the colon is brought up through protocols with the laparoscopic approach an opening on the (stoma) are showing decreasing complications, 8 to form an ostomy. Waste will empty hospital stay, and decreasing readmissions. through the ostomy into a pouch that is fixed around the stoma on the abdomen. Non-Surgical Treatment Laparoscopic Colectomy Some diseases of the intestines may be Several small incisions are made in the treated with medication. Depending on the abdomen. Ports or hollow tubes are inserted stage of cancer, radiation and into the openings. Surgical tools and a lighted may also be part of the treatment plan. scope are placed through the ports. The 3 Colectomy Risks of These Procedures SAMPLE

Risks Based on the ACS Risk Calculator* Partial Colectomy with Anastomosis Procedure from the ACS Risk Calculator – March 5, 2019

Average Patient Risks Keeping You Informed Percentage

Pneumonia: 2.6% Stopping smoking before your operation and taking deep Infection in the lungs breaths plus getting up and walking after can help prevent pneumonia.

Heart complication: 1.1% Problems with your heart or lungs can sometimes be Heart attack or sudden stopping of the heart worsened by general anesthesia. Your anesthesia provider will take your history and suggest the best option for you.

Wound Infection 10.7% Antibiotics are generally given before the surgery. You may be asked to use special soap before and after your surgery.

Urinary tract infection: 1.9% A Foley catheter may remain in the bladder a few days Infection of the bladder or kidneys after surgery to drain the urine. Adequate fluid intake and catheter care decrease the risk of bladder infection.

Blood clot: 2% Longer surgery and bed rest increase the risk. Getting up, A clot in the legs that can travel to the lung walking 5 to 6 times/day, and wearing support stockings reduce the risk.

Renal (kidney) failure: 1.2% Pre-existing renal insufficiency, fluid imbalance, Type 1 Kidneys no longer function in making urine diabetes, over 65 years of age, antibiotics, and other and/or cleaning the blood of toxins medications may increase the risk.

Return to surgery 6.1% Bleeding or a bowel leakage may cause a return to surgery. Your surgical and anesthesia team is prepared to reduce all risks of return to surgery.

Death 1.5% Your surgical team will review for possible complications and be prepared to decrease all risks.

Discharge to or 8.4% rehabilitation facility

Risk of anastomotic leak: 4.1% Increased age, emergency surgery, obesity, the use of steroids A leak from the connection that is made for and chemotherapy, and radiation as well as between two ends of the intestine smoking and alcohol before surgery may increase the risk.11 Ask your surgeon about risks for people like me.

*1% means that 1 of 100 people will have this complication

The ACS Surgical Risk Calculator estimates the risk of an unfavorable outcome. Data is from a large number of patients who had a surgical procedure similar to this one. If you are healthy with no health problems, your risks may be below average. If you smoke, are obese, or have other health conditions, then your risk may be higher. This information is not intended to replace the advice of a doctor or provider. To check your risks, go to the ACS Risk Calculator at riskcalculator.facs.org.

4 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Expectations: Preparation Colectomy and Expectations

What to Bring Preparing for Your Operation ●●Insurance card and identification Questions Home Medication ●●Advance directive to Ask Bring a list of all of the medications, vitamins, ●●List of and nutritional supplements that you are taking. About My Home Your medication may have to be adjusted before ●●Loose-fitting, comfortable clothes Medications your operation. Some medications can affect ●●Slip-on shoes that don’t require • What medications your recovery, blood clotting, and response to you to bend over should I stop the anesthesia. Most often you will take your ●●Leave jewelry and valuables at home taking before morning medication with a sip of water. my operation? What You Can Expect Anesthesia An identification (ID) bracelet and • Should I take Let your anesthesia provider know if you have bracelet with your name and hospital/ any medicines , neurologic disease (epilepsy, stroke), heart clinic number will be placed on your wrist. on the day of disease, stomach problems, lung disease (asthma, These should be checked by all health team my operation? emphysema), endocrine disease (diabetes, thyroid members before they perform any procedures conditions), or loose teeth; if you smoke, drink alcohol, or give you medication. Your surgeon About My use drugs, or take any herbs or vitamins; or if you have will mark and initial the operation site. Operation a history of nausea and vomiting with anesthesia. Fluids and Anesthesia • What are the risks If you smoke, you should let your surgical team and of know. You should plan to quit. Quitting before your An intravenous line (IV) will be started to general anesthesia? surgery can decrease your rate of respiratory and give your fluids and medication. For general wound complications and increase your chances anesthesia, you will be asleep and pain-free. • What procedure of staying smoke-free for life. Resources to help you A tube will be placed down your throat to will be used to quit may be found online at facs.org/quitsmoking or help you breathe during the operation. repair the colon? lungusa.org/stop-smoking. Laparoscopic After Your Operation or open? Length of Stay You will be moved to a recovery room • Will the colon be You may stay in the hospital for about 2 nights where your heart rate, breathing rate, sutured or do I after a laparoscopic repair or longer after an open oxygen saturation, blood pressure, and need to be trained colectomy.12 You may have a catheter in place in urine output will be closely watched. Be how to care for your bladder to measure and drain your urine sure that all visitors wash their hands. an ostomy? for a few days. Severe nausea, vomiting, or the Preventing Pneumonia inability to pass urine may result in a longer stay. • What are the risks and Blood Clots of this procedure? Movement and deep breathing after your The Day of Your Operation operation can help prevent postoperative • Will you be performing the ●●Do not eat for 4 hours or drink anything but clear complications such as blood clots, fluid entire procedure liquids for at least 2 hours before the operation. in your lungs, and pneumonia. Every hour, take 5 to 10 deep breaths and yourself? ●●Shower and clean your abdomen and groin hold each breath for 3 to 5 seconds. area with a mild antibacterial soap. • What level of pain When you have an operation, you are at should I expect ●●Brush your teeth and rinse your mouth out risk of getting blood clots because of not and how will it with mouthwash. moving during anesthesia. The longer and be managed? ●●Do not shave the surgical site; your surgical team more complicated your surgery, the greater will clip the hair nearest the incision site. the risk. This risk is decreased by getting up • How long will it be and walking 5 to 6 times per day, wearing before I can return special support stockings or compression to my normal boots on your legs, and, for high-risk patients, activities—work, taking a medication that thins your blood. driving, and lifting?

5 Colectomy Your Recovery and Discharge SAMPLE

Your Recovery Keeping You and Discharge Informed Thinking Clearly If You Have a Stoma If general anesthesia is given or if you need to If you have a stoma constructed, take narcotics for pain, it may cause you to feel Handwashing Steri-Strips® your stool will pass through it into diff erent for 2 or 3 days, have diffi culty with a special pouch that is attached memory, or feel more tired. You should not Wound Care to the skin around the stoma. The drive, drink alcohol, or make any big decisions To learn more about how to care for your for at least 2 days. pouch will have an opening at the wound, go to facs.org/woundcare. end for the stool to drain through. Nutrition It will need to be changed daily. ● Always wash your hands before and after Before you leave the hospital, If you follow an enhanced recovery protocol, touching near your incision site. you will be shown how to care for the aim is to return to a normal diet as soon as ● Do not soak in a bathtub until your stitches, your stoma and supplies. Some possible. Right after surgery, you will be able to Steri-Strips®, or staples are removed. You stomas may be temporary and drink water and be provided with anti-nausea can usually shower within 2 days unless you closed at a later date, while others medication if you need it. On postoperative are told not to. may be permanent, depending day 1, you can eat a normal diet. IV fl uids will ● A small amount of drainage from the on your diagnosis and surgery. continue for 1 to 2 days after the surgery. For incision is normal. If the dressing is soaked up to 4 weeks, a low-residue/low-fi ber diet You can learn more about how with blood, call your surgeon. is recommended to reduce the amount and to care for your stoma by frequency of stools. This reduces trauma to the ● If you have Steri-Strips in place, they will reviewing the American College healing intestinal reconnection.13 Continue to fall off in 7 to 10 days. of Surgeons Ostomy Home drink about 8 to 10 glasses of fl uid per day. A Skills Kit available online at ● If you have a glue-like covering over dietician can help you understand your diet. facs.org/adultostomy. You will the incision, allow the glue to fl ake off continue to have support in Activity on its own. the care of your stoma once ● Avoid wearing tight or rough clothing. It ● After surgery, you will sit in a chair. The you’re home and caring for may rub your incisions and make it harder next day, you should be up and walking the it will become part of your for them to heal. routine if it is permanent. hallway. Your pain should be managed with pain medication. Get up and walk every ● Protect your new skin, especially from sun. hour or so to prevent blood clot formation. The sun can burn and cause darker scarring. ● You may be able to resume most normal ● Your will heal in about 4 to 6 weeks activities in 1 or 2 weeks. These activities and will become softer and continue to include showering, driving, walking up fade over the next year. stairs, working, and engaging Bowel Movements in sexual activity.14 In the fi rst 2 weeks, your bowel movements Work and Return to School may be more frequent and looser than usual ● You may return to work after you until you fully resume eating solid food. Avoid feel healthy, usually 1 to 2 weeks straining with bowel movements. Be sure you Do not lift anything after laparoscopic repair and 2 to are drinking 8 to 10 glasses of fl uid each day. over 10 pounds. 3 weeks for open procedures. A gallon of milk Pain You will not be able to lift anything over weighs 9 pounds. ● 10 pounds, climb, or do strenuous activity The amount of pain is diff erent for each for 4 to 6 weeks following surgery. person. The new medicine you will need after your operation is for pain control, and your doctor will advise how much you should take. You can use throat lozenges if you have sore throat pain from the tube placed in your throat during your anesthesia.

6 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Colectomy

Narcotic (Opioid) Pain Medication When to Contact Narcotics or opioids are used when you Keeping You Your Surgeon cannot function due to severe pain. Possible Informed Contact your surgeon if you have: side effects of narcotics are sleepiness, lowered blood pressure, heart rate, and breathing rate; Pain Control ●●Pain that will not go away skin rash and itching; constipation; nausea; without Medicine ●●Pain that gets worse and difficulty urinating. Some examples of narcotics include morphine, oxycodone Distraction helps you focus on ●●A fever of more than 101°F (38.3°C) (Percocet®/Percodan®), and hydromorphone other activities instead of your ●●Repeated vomiting (Dilaudid®). Medications can be given to pain. Listening to music, playing ●●Swelling, redness, bleeding, or bad- control many of the side effects of narcotics. games, or other engaging activities can help you cope smelling drainage from your wound site To learn more about safe and effective pain with mild pain and anxiety. ●●Strong or continuous abdominal pain control and how to dispose of all unused or swelling of your abdomen opioids, go to facs.org/safepaincontrol. Guided imagery helps you direct and control your emotions. Close ●●No bowel movement 2 to 3 days your eyes and gently inhale after the operation and exhale. Picture yourself in the center of somewhere OTHER INSTRUCTIONS beautiful. Feel the beauty Pain Control surrounding you and your The amount of pain you have after a colectomy emotions coming back to your will depend on your other health factors control. You should feel calmer. and how much of your colon was removed. After your surgery, you may have a patient- controlled anesthesia pump (PCA). You will Distraction have a button that you push when you start to feel it’s time for pain medicine. The pump is set so that you cannot get too much medicine. You may have this pump until you are able to eat and take pain medicine by mouth. Everyone reacts to pain in a different way. A scale from 0 to 10 is used to measure pain. At a “0,” you do not feel any pain. A “10” is the worst pain you have ever felt. Following a laparoscopic procedure, pain is sometimes felt in the shoulder. This is due to the gas inserted into your abdomen during the procedure. Moving and walking help to decrease the gas and the shoulder pain. FOLLOW-UP APPOINTMENTS Non-Narcotic Pain Medication Guided imagery WHO: Most non-opioid are classified as non-steroidal anti-inflammatory drugs (NSAIDs). They are used to treat mild pain and DATE: inflammation or are combined with narcotics to treat severe pain. Possible side effects of NSAIDs are stomach upset, bleeding in the PHONE: digestive tract, and fluid retention. These side effects usually are not seen with short- term use. Let your doctor know if you have heart, kidney, or problems. Examples of NSAIDs include ibuprofen, Motrin®, Aleve®, and Toradol® (given as a shot). 7 AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION Colectomy More Information SAMPLE

For more information, please go to the American College of Surgeons Patient Education website at facs.org/patient education. For a complete review of colectomy, consult Selected Readings in , “Colon, Rectum & Anus, Part II,” 2015 Vol. 41 No. 5 at facs.org/SRGS.

GLOSSARY REFERENCES Advance directives: Documents Ileus: A decreased motor activity The information provided in this report is chosen from recent articles signed by a competent person of the digestive tract due to based on relevant clinical research or trends. The research below does giving direction to health care nonmechanical causes. not represent all that is available for your surgery. Ask your doctor if he or providers about treatment choices. she recommends that you read any additional research. Local anesthesia: The loss of Anastomosis: The connection of sensation only in the area of the 1. American Cancer Society. Colorectal Cancer. 2014. www.cancer.org/ two structures, like two ends of the body where an anesthetic drug is cancer/colonandrectumcancer/detailedguide/colorectal-cancer-diagnosed. intestines. applied or injected. Accessed August 13, 2014. Computerized tomography Nasogastric tube: A soft plastic 2. American College of Surgeons. ACS Risk Calculator. (CT) scan: A diagnostic test using tube inserted in the nose and down http://riskcalculator.facs.org. Accessed March 5, 2019. X-ray and a computer to create to the stomach. It is used to empty 3. Fry RD, Mahmoud NN, Maron DJ, et al. Colon and Rectum. In: Townsend a detailed, three-dimensional the stomach of contents and gases CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook picture of your abdomen. A CT to the rest of the bowel. of Surgery. 19th ed. Philadelphia, PA: Saunders Elsevier;2012:1320. scan is commonly used to detect abnormalities or disease inside the Stoma: An artificial opening of the 4. Fry RD, Mahmoud NN, Maron DJ, et al. Colon and Rectum. In: Townsend abdomen. intestine or urinary tract onto the CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook abdominal wall. of Surgery. 19th ed. Philadelphia, PA: Saunders Elsevier;2012:1330. Electrocardiogram (ECG): Measures the rate and regularity of Ultrasound: Sound waves are used 5. Mayo Clinic. Diseases and Conditions: Crohn’s Disease. 2015. heartbeats as well as any damage to determine the location of deep www.mayoclinic.org/diseases-conditions/crohns-disease/basics/symptoms/ to the heart. structures in the body. A hand roller con-20032061. Accessed October 1, 2014. is placed on top of clear gel and 6. Maartnese S, Dunker MS, Slors JR, et al. Laparoscopic-assisted versus General anesthesia: A treatment rolled across the abdomen. open ileocolic resection for Crohn’s disease: A randomized trial. with certain medicines that puts Ann Surg. 2006;243:143-149. you into a deep sleep so you do Urinalysis: A visual and chemical not feel pain during surgery. examination of the urine, most 7. Dardik A, Berger D, Rosenthal R. Surgery in the Geriatric Patient. In: often used to screen for urinary Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Hematoma: A collection of blood tract and kidney disease. Textbook of Surgery. 19th ed. Philadelphia, PA: Saunders Elsevier;2012:350. that has leaked into the tissues of the skin or in an organ, resulting 8. Delaney CP, Brady K, Woconish D, et al. Towards optimizing perioperative from cutting in surgery or the colorectal care: Outcomes for 1,000 consecutive patients undergoing blood’s inability to form a clot. laparoscopic colon procedures using enhanced recovery pathways. Am J Surg. 2012;203:353-355. 9. Fry RD, Mahmoud NN, Maron DJ, et al. Colon and Rectum. In: Townsend DISCLAIMER CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook This information is published to educate you about your specific surgical of Surgery. 19th ed. Philadelphia, PA: Saunders Elsevier;2012:1377. procedures. It is not intended to take the place of a discussion with a qualified 10. Simorov A, Shaligram A, Shostrom V, et al. Laparoscopic colon resection surgeon who is familiar with your situation. It is important to remember that each trends in utilization and rate of conversion to open procedure: a individual is different, and the reasons and outcomes of any operation depend national database review of academic medical centers. Ann Surg. 2012 upon the patient’s individual condition. Sep;256(3):462-8. doi: 10.1097/SLA.0b013e3182657ec5. The American College of Surgeons (ACS) is a scientific and educational 11. Davis, B and Rivadeneira, D. Complications of colorectal anastamosis. organization that is dedicated to the ethical and competent practice of surgery; it Surg Clin N Am. 2013;93:72. was founded to raise the standards of surgical practice and to improve the quality 12. Kehlet H. Fast-track . Lancet. 2008;371:791-793. of care for the surgical patient. The ACS has endeavored to present information for prospective surgical patients based on current scientific information; there 13. University of Chicago Medicine. Frequently asked questions about is no warranty on the timeliness, accuracy, or usefulness of this content. colectomy (colon resection). 2015. www.uchospitals.edu specialties/general-surgery/services/colectomy.html. Accessed Oct 1, 2014. Reviewed 2014 and 2015; 14. SAGES. Patient Information for Laparoscopic Colon Resection. 2014. Revised 2019 by: www.sages.org/publications/patient-information/patient-information- Nancy Strand, RN, MPH for-laparoscopic-colon-resection-from-sages. Accessed Oct 1, 2014. Kathleen Heneghan, RN, PhD, PNP-C Robert Roland Cima, MD, FACS

8 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation

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