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Preparing for Outpatient Surgery


The majority of ano-rectal surgical procedures are done as an out-patient. Dr. Pennington and Dr. Sheffey perform the majority of these procedures at East Tennessee Ambulatory Surgery Center (ETASC), and Franklin Woods Community Hospital (FW). Outpatient procedures can also be done at the Johnson City Medical Center (JCMC).  

It is very important to arrive on time. After check in you will be taken to the pre-operative holding area. Your doctor will speak to you here before the procedure. Out patient procedures generally do not take long so it is important to have a driver with you and available for discharge instructions. Dr. Pennington and Dr. Sheffey will speak to your driver with your permission.



Margaret will schedule your procedure and then call you with the details. Paperwork will also be mailed to you. You will have a pre-operative appointment with the facility several days before your procedure. Margaret will provide you with forms required by the facility. At ETASC you will meet with a nurse and an anesthesiologist if necessary.  Be sure to bring your medications. Blood work will be done as needed. You will be given payment details at this visit also. JCMC and FW hospitals may schedule a pre-operative phone call. During this call a nurse will go over your medical history and medications. If a further appointment is needed it is arranged during that call. 


Pre-Operative Clearance

Depending on unique factors pertaining to your age and medical history you may be sent for a pre-operative clearance to be performed by your primary care physician, cardiologist, or pulmonologist. Pre-operative testing usually consists of a physical examination, an EKG to check your heart, and a chest X-Ray to check your pulmonary status. If any of these tests are abnormal additional tests may be ordered. It is important to discover any abnormalities before an elective surgical procedure. If you are on anticoagulant medications, such as Coumadin (warfarin) or Plavix, we will need authorization from the prescribing physician to stop these medications.

Medication & Supplement Management

​ During the pre-operative period it is important to manage your medications in preparation for surgery. Be sure to communicate all medications and supplements. Some medications may need to be discontinued prior to surgery.


The medication phenteramine must be stopped two weeks prior to any type of anesthesia.

If you are on any anticoagulants, including aspirin, they must be stopped a week prior to your procedure. Coumadin (warfarin) must be stopped four days prior to your procedure. You may be given clearance to stop Coumadin, or you may be given a prescription for Lovenox to use during this time. Here is a list of common anticoagulant Medications:

  • Coumadin (warfarin)


  • Plavix (clopidogrel)


  • Aggrenox (dipyridamole + aspirin)


  • Ticlid (ticlopidine)


  • Pletal (cilostazole)


  • Effient (prasugrel)


  • Brilinta (ticagrelor)


  • Pradaxa (dabigatran)


  • Xarelto (rivaroxaban)


  • Eliquis (apixaban)



Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) can also cause bleeding during surgical procedures and must be stopped one week prior to your procedure. Here is a list of Nonsteroidal Anti-inflammatory Drugs (NSAID's) that can increase bleeding:

  • Motrin/Advil (ibuprofen)


  • Orudis KT, Oruvail, Actron (ketoprofen)


  • Clinoril (sulindac)


  • Aleve, Naprosyn, EC-Naprosyn, Naprelan, Anaprox, Anaprox-DS, Vimovo (naproxen)


  • Lodine XL, Lodine (etodolac)


  • Nalfon (fenoprofen)


  • Arthrotec, Cataflam, Voltaren, Cambia, Voltaren-XR, Zipsor, Flector Patch, Voltaren Gel (diclofenac)


  • Ansaid (flurbiprofen)


  • Sprix, Toradol, Toradol IV/IM (ketorolac)


  • Feldene (piroxicam)


  • Indocin SR, Indocin (indomethacin)


  • Ponstel (mefenamic acid)


  • Mobic (meloxicam)


  • nabumetone (Relafen)


  • Daypro (oxaprozin)


  • Actron, Orudis KT, Orudis, Oruvail (ketoprofen)


  • Duexis (famotidine and Ibuprofen)


  • Meclofen (meclofenamate)


  • Tolectin (tolmetin)


  • Disalcid (salsalate)


  • Trilisate (choline magnesium trisalicylate)


  • Dolobid (diflunisal)


  • Celebrex (celecoxib)

Diabetes medications may be adjusted during the perioperative period. If you are diabetic you may need to check your sugar more frequently in the peri-operative period. If you need to drink juice do not hesitate to correct a low sugar. 

For patients with Type I diabetes, you will continue basal insulin without diminishing the dose. Do not take short acting insulin the morning of the procedure. If you are treated with an insulin pump, you may continue your usual infusion rate.

For patients with Type II diabetes do not take short-acting insulin the morning of the procedure. If you take glargine insulin (Lantus) at bedtime, take 1/2 your usual dose the night before the procedure. If you take glargine (Lantis) in the morning, take 1/2 your usual dose. For patients taking detemir insulin (Levemir) you may take your usual dose.

Oral medications like glucophage XR, and chlorpropamide (Diabenase) should not be taken the evening prior, or the morning of the procedure. Do not take Glipizide, Glyburide, Glimepride, Prandin, Starlix, Precose, Glyset, or Voglibose the morning of your procedure. Avandia or Actos should generally be held as well. Byetta, Symlin, Galvus, or Januvia should also be held the morning of your procedure. 

Vitamins and Supplements present an interesting challenge to physicians and surgeons. There are literally over 40,000 supplements and supplement combinations of varying doses on the market. The following supplements are known to possibly increase bleeding risks: Bilberry, Cayenne (Red Pepper), Dong Quai (angelica), Echinacea, Evening Primrose Oil, Feverfew, Fish Oil, Flaxseed Oil, Garlic, Ginger, Ginkgo Biloba, Ginseng, Hawthorne, Kava Kava, Licorice Root, Ma Huang, Melatonin, Red Clover, St. John's Wort, Valerian, Vitamin E, Yohimbe. Dr. Pennington recommends that you discontinue all vitamins and supplements a week prior to your procedure.

Bowel Preparation

A bowel preparation is usually not necessary for anal canal surgery. For some rectal surgeries you may be asked to use two Fleet's enemas the morning of the surgery prior to leaving home. 

The Day of Surgery

In preparing for surgery, do not wear make up or hair spray. Removed hearing aids, contacts, and dental partials. Be prepared to remove glasses and dentures in the preoperative area. Remove all jewelery and body piercings and leave them at home.

You will be able to speak to Dr. Pennington or Dr. Sheffey prior to your procedure. They will speak to your family or driver after the procedure with your permission. Be sure to arrange for a driver to take you home after the procedure. You may not leave the facility by a cab or public transportation. 


Discharge Instructions

You will be given a prescription for pain medications. We recommend that you pick up your medications on the way home. Pain medications can cause constipation so we recommend you also pick up an over the counter stool softener. There are typically no restrictions after ano-rectal surgery concerning diet or activity but do apply common sense. You may want to avoid heavy meals, spicy foods, or take-out until your bowel movements are normal.You would not want to try to exercise for several days. Concerning bowel movements we recommend you run a warm bath, take a pain tablet and wait several minutes, then use the bathroom followed by soaking in warm water. You may use a Sitz bath as well. Everyday the pain with bowel movements will ease off. If you have not had a bowel movement in several days, you may use Miralax as directed. Should you have any problems, please call the office.

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