Background: Robot-assisted laparoscopy (RAL) is an important surgical method that is expanding quickly. Despite its swift development, the research situation varies and from several perspectives there is a general lack of scientific evidence for RAL as a method. Aim: The aim of the study was to investigate the perioperative nursing care of the patient undergoing RAL, with focus on the intraoperative climate and nursing measures. Method: Data was collected through semi-structured interviews with perioperative registered nurses (RN). The interviews were analyzed using thematic analysis (TA) to identify and present patterns and themes. Results: The patients intraoperative care is affected by RAL in several ways. For the perioperative RN, there is a lot to keep track of and think about in order to maintain asepsis and to ensure the patient's physical safety during these procedures. The positioning of the patient is important in order to avoid pressure ulcers and press-related pain injuries, as well as over-stretching and nerve damage. It is a larger sterile area in a narrow environment where it can be difficult to get an overview and maintain the asepsis. Discussion: The study's results have contributed to new meaningful knowledge to the perioperative care in RAL. The difficulties with preparations and positioning were risk factors for the patient, in contrast with the advantages of the surgery for the same, which could however be improved and developed with the help of guidelines and follow-up. / Bakgrund: Robotassisterad laparoskopi (RAL) är en viktig kirurgisk metod som växer och utvecklas snabbt. Trots den snabba utvecklingen varierar forskningsläget och från flera perspektiv finns det en allmän brist på vetenskapliga bevis för RAL som en metod. Syfte: Syftet med denna studie var att undersöka den perioperativa omvårdnaden av patienten vid RAL, med fokus på den intraoperativa miljön och omvårdnadsåtgärderna. Metod: Data samlades in genom semistrukturerade intervjuer med operationssjuksköterskor. Intervjuerna analyserades med hjälp av tematisk analys (TA) för att identifiera och presentera mönster och teman. Resultat: Patientens intraoperativa vård påverkas av RAL på flera sätt. För operationssjuksköterskor finns det mycket att hålla reda på och tänka på för att upprätthålla aseptiken och för att säkerställa patientens fysiska säkerhet under dessa ingrepp. Placeringen av patienten är viktig för att undvika trycksår ​​och tryckrelaterade skador, liksom översträckning och nervskador. Det är ett större sterilt område i en trång miljö där det kan vara svårt att få en överblick och upprätthålla aseptiken. Diskussion: Studiens resultat har bidragit till ny meningsfull kunskap om den perioperativa vården inom RAL. Svårigheterna med hjälpmedel och positionering var riskfaktorer för patienten, i motsats till fördelarna med operationen för detsamma, vilket dock kunde förbättras och utvecklas med hjälp av riktlinjer och uppföljning.

Prostatacancer drabbar cirka 9600 svenska män årligen. Behandlingsalternativ finns i flera olika former och patienten kan i samråd med en medicinsk expertis välja den behandling som är mest lämplig. Radikal prostatektomi är en av behandlingsformerna som finns att välja, det innebär att prostatakörteln avlägsnas kirurgiskt och syftet med ingreppet är kurativt. Borttagning av prostatakörteln leder till en rad förändringar i männens livsstil samt på ett emotionellt plan. I vårdandet av prostatacancerpatienter har sjuksköterskan en viktig roll i att undervisa, rådgöra och stödja dessa patienter som ska genomgå eller har genomgått prostatektomi. Sjuksköterskans roll är att förbereda patienten preoperativt men också postoperativt där information och utbildning är en viktig del för denna patientgrupp och deras familjemedellemmar. Syfte med denna studie var att belysa patientens upplevelser av livet efter att ha genomgått prostatektomi. Studien är en litteraturstudie baserad på kvalitativa och kvantitativa artiklar. Tio artiklar valdes ut och granskades med hjälp av Fribergs granskningsmall. Fyra olika teman framkom. Det första; Att vara inkontinent, vilket handlar om hur männen med prostata cancer hanterar sina upplevelser i samband med urinläckage på grund av sjukdomen, hur det påverkar vardagslivet och männens syn på sin kropp. Det andra temat: Att vara impotent, beskriver hur impotens kan påverka männens identitet, bilden av sig själva, manligheten och känslor som rör sexualiteten. Det tredje temat Existentiella tankar, beskriver hur männen upplever sin situation i nuet och vilka funderingar de har om sin framtid. Det fjärde temat Behovet av stöd och uppföljning, beskriver uppföljning av vård och behandling för patienten samt vikten av information och undervisning. / Program: Sjuksköterskeutbildning

This thesis focused on the acute management of patients with ST-segment elevation myocardial infarction (STEMI) in an effort to provide information that may improve outcome. The aim was to evaluate the efficacy and safety of bivalirudin versus unfractionated heparin (UFH) in STEMI patients during primary PCI. Furthermore, to provide pharmacodynamic data of novel ways of ticagrelor administration compared to standard tivcagrelor. Additionally, to identify subgroups of patients, such as women who may derive greater benefit from specific antithrombotic strategies due to their risk/benefit profile. Finally, to evaluate current formulas for estimation of renal function in the acute phase of STEMI. In Paper I, all STEMI patients in Sweden between 2008 and 2014, treated with primary PCI and UFH or bivalirudin were included in our analysis. Of the total population of 23 800 patients, 8 783 (36.9%) were included in the UFH group and 15 017 (63.1%) in the bivalirudin group. Concomitant GPI administration was 68.5% in the UFH arm compared to 3.5% in the bivalirudin arm (p<0.01).The adjusted incidence of 30-day mortality was not significant different between the two groups (UFH vs bivalirudin, adjusted HR 0.94; 95% CI 0.82 -1.07). The adjusted risk for 1-year mortality, 30-day and 1-year stent thrombosis and re-infarction did not differ significantly between the two groups. In contrast, patients treated with UFH had a significantly higher incidence of major in-hospital bleeding (adjusted OR 1.62; 95%CI 1.30 -2.03). In Paper II pharmacodynamic data of chewed or crushed ticagrelor compared to standard ticagrelor loading dose (LD) was assessed in 99 patients with stable angina. Platelet reactivity (PR) was assessed with VerifyNow before, 20 and 60 minutes after LD. High Residual platelet reactivity (HRPR) was defined as > 208 P2Y12 reaction units (PRU). Chewed ticagrelor tablets resulted in significantly lower PRU values compared to crushed or integral tablets at 20 and 60 minutes. Crushed ticagrelor LD resulted in significantly lower PRU values compared to integral tablets at 20 minutes whereas no difference was observed at 60 minutes. At 20 minutes, no patients had HRPR with chewed ticagrelor compared to 68% with integral and 30% with crushed ticagrelor LD (p<0.01). In Paper III we presented a pre-specified gender analysis of the ATLANTIC trial including 1 862 STEMI patients that were randomly assigned to pre-hospital versus in-hospital administration of 180mg ticagrelor. Women were older and had higher TIMI risk score. Women had a 3-fold higher risk for all-cause mortality compared to men (5.7% vs 1.9%, HR 3.13, 95% CI 1.78 – 5.51). However, after adjustment for baseline characteristics, the difference was lesser and no longer significant (HR 1.98, 95% CI 0.97 – 4.04). Female gender was not an independent predictor of risk for bleeding after multivariable adjustments (BARC type 3-5 HR 1.52, 95% CI 0.74-3.09). There was no interaction between gender and efficacy or safety of randomised treatment. In Paper IV, forty patients with PCI- treated STEMI were included between November 2011 and February 2013. We validated the performance of the Cockcroft-Gault (CG), the Modification of Diet in Renal Disease (MDRD-IDMS), the Chronic Kidney Disease Epidemiology (CKD-EPI) and the Grubb relative cystatin C (rGCystC) equations for estimation of GFR against measured GFR (mGFR) during the index hospitalisation for STEMI. MDRD-IDMS and CKD-EPI demonstrated a good performance to estimate GFR with accuracy within 30% (P30) 82.5% vs 82.5%, respectively. CKD was best classified by CKD-EPI (Kappa 0.83). CG showed the worst performance with the lowest P30. The rG-CystC equation had a marked bias of -17.8% and significantly underestimated mGFR (p=0.03). Conclusions – In STEMI patients treated with primary PCI, bivalirudin should be preferred in patient at high risk for bleeding. With crushed or chewed ticagrelor tablets a more rapid platelet inhibition may be achieved, compared with standard integral tablets. In STEMI patients, fast and potent platelet inhibition with chewed ticagrelor may reduce the risk of early stent thrombosis and patients treated with a less aggressive antithrombotic strategy, such as UFH or bivalirudin monotherapy, may derive a greater benefit. Although gender differences in adverse outcomes could mainly be explained by older age and clustering of comorbidities in women, a bleedreduction strategy in women with high risk characteristics is warranted in order to improve their outcome. Regardless the choice of antithrombotic strategy, dose adjustment of drugs cleared by kidneys based on GFR estimation is of crucial importance. MDRD and CKD-EPI should be the formulas used for estimation of GFR in STEMI patients

<p>Atrial fibrillation is a common disease. With pharmacological therapy most patients with atrial fibrillation have moderate or little symptoms, but a number of patients have severely symptomatic disease. This study evaluates two new non-pharmacological therapies for atrial fibrillation, the Maze procedure and atrial overdrive pacing.</p><p>In the patients planned for Maze surgery the quality of life, assessed with the SF-36 questionnaire, was very low before the operation. The quality of life was markedly improved 6 and 12 months after the Maze operation, and was comparable to values of the general Swedish population.</p><p>In the patients with sinus rhythm before surgery, the atrial size and transport function was assessed with echocardiography, and the autonomic balance was assessed with heart rate variability (HRV). The sizes of both atria were reduced and the transmitral early filling / atrial filling (E/A) ratio was increased at 6 months after the operation compared to before. A progressive increase of the E/A ratio was seen during the 24 months follow-up period, indicating a progressive decline of the left atrial transport function.</p><p>All components of HRV, including the parameters expressing sympathetic and parasympathetic modulation, were markedly decreased early after the Maze procedure compared to before. Late after the operation all components of HRV were still markedly depressed. This is interpreted as a partial autonomic denervation of the heart</p><p>Single-site right atrial overdrive pacing with two different levels of overdriving was compared with no pacing in patients with paroxysmal atrial fibrillation in a cross-over study. Overdrive pacing reduced the median number of episodes of atrial fibrillation with 50% compared to no pacing. There was no difference between medium rate overdrive pacing and high rate overdrive pacing.</p>

Atrial fibrillation is a common disease. With pharmacological therapy most patients with atrial fibrillation have moderate or little symptoms, but a number of patients have severely symptomatic disease. This study evaluates two new non-pharmacological therapies for atrial fibrillation, the Maze procedure and atrial overdrive pacing. In the patients planned for Maze surgery the quality of life, assessed with the SF-36 questionnaire, was very low before the operation. The quality of life was markedly improved 6 and 12 months after the Maze operation, and was comparable to values of the general Swedish population. In the patients with sinus rhythm before surgery, the atrial size and transport function was assessed with echocardiography, and the autonomic balance was assessed with heart rate variability (HRV). The sizes of both atria were reduced and the transmitral early filling / atrial filling (E/A) ratio was increased at 6 months after the operation compared to before. A progressive increase of the E/A ratio was seen during the 24 months follow-up period, indicating a progressive decline of the left atrial transport function. All components of HRV, including the parameters expressing sympathetic and parasympathetic modulation, were markedly decreased early after the Maze procedure compared to before. Late after the operation all components of HRV were still markedly depressed. This is interpreted as a partial autonomic denervation of the heart Single-site right atrial overdrive pacing with two different levels of overdriving was compared with no pacing in patients with paroxysmal atrial fibrillation in a cross-over study. Overdrive pacing reduced the median number of episodes of atrial fibrillation with 50% compared to no pacing. There was no difference between medium rate overdrive pacing and high rate overdrive pacing.

Background: Despite the recent improvements in surgical techniques and postoperative patient care, atrial fibrillation (AF) remains the most frequent complication after cardiac surgery. Although postoperative AF is often regarded as a benign clinical condition, this arrhythmia has significant adverse effects on patient recovery and postoperative survival. Its exact pathophysiology has not yet been elucidated. The present thesis aims to analyze AF risk factors and their interaction, pre-existing histological explanatory alterations of the atrium, the AF impact on postoperative survival and the compliance of a prophylactic drug regimen. Methods: During a 10-year period, consecutive cardiac surgery cases with complete data on AF occurrence and postoperative survival were extracted. All patients were operated on for coronary or valvular surgery, with cardiopulmonary bypass (CPB). Hospital and long-term survival data were obtained from Swedish population registry. Study I) Isolated coronary artery bypass grafting (CABG, n=7056), aortic valve replacement (n=690) and their combination (n=688) were considered. Independent AF risk factors and AF effects on early and 1 year mortality were investigated. Study II) Patients affected by postoperative AF among isolated CABG patients (n=7621), valvular surgeries (n=995) and their combination (n=879) were studied. Long-term survival was obtained and prognostic factors identified. Study III) Seventy patients were randomized to on-pump (n=35) or off-pump (n=35) CABG. Samples from the right atrial appendage were collected and histology was evaluated by means of light and electronic microscopy with reference to preexistent alterations related to postoperative AF. Study IV) Cardiac surgery patients with complete data on smoking status (n=3245) were reviewed. Effects of smoking on AF development and interaction among variables were explored. Study V) CABG patients without clinical contraindications to receive oral sotalol (80 mg twice daily) and magnesium were prospectively enrolled (n = 49) and compared with a matched contemporary control CABG group (n = 844). The clinical compliance to the AF prophylactic drug regimen was tested. Results: The overall AF incidence was around 26%, subdivided into 23%, 40% and 45% for isolated CABG, valve procedures and their combined surgeries, respectively. Age was the strongest predictor of postoperative AF. Coronary disease superimposed risk factors with reference to myocardial conditions at CPB weaning. Considering the preoperative smoking condition, smokers demonstrated a reduced AF incidence compared to non-smokers (20% versus 27%, p&lt;0.001). An interaction between smoking status and inotropic support was observed: without this interaction smoking conferred a 46% risk reduction of AF (p=0.011). At the histological level, myocyte vacuolization and nuclear derangement represented anatomical independent AF predictors (p=0.002 and p=0.016, respectively). CPB exposure was not associated to postoperative AF nor histological changes. Although, postoperative AF increases the length of hospitalization in all patient groups, it did not affect the hospital survival. However, AF independently impaired the late survival, a phenomenon seen in the CABG group only. With reference to the tested sotalolmagnesium drug regimen, only 55% of CABG patients were compliant to the treatment, with marginal effects on AF occurrence. Conclusions: In addition to age, details at the CPB weaning period, pre-existing histopathological changes, the hyperadrenergic state and catecholamines are key mechanisms in the pathophysiology of postoperative AF. In particular, the CPB period hides valuable information for timely AF prophylactic stratifications. Further, compliance effects due to patient selection should also be considered in a prophylactic therapy model. Postoperative AF increases late mortality after isolated CABG surgery, but not after valvular procedures. Although the mechanisms are unclear, our results draw the attention to possible AF recurrence after hospital discharge, indicating a strict postoperative surveillance.

Introduction: During cardiac surgery aided by cardiopulmonary bypass (CPB) the autotransfusion of pericardial suction blood (PSB) is regarded mandatory to limit allogeneic blood exposure. PSB is however proposed as a source of lipid microemboli and to contribute to brain damage. This thesis addresses the logistics of allogeneic blood transfusion during coronary artery bypass grafting (CABG), the embolic potential of reinfused PSB, and means to reduce PSB fat contamination, investigated both clinically and experimentally. Methods: Study I) Patients undergoing CABG surgery (n=2469) were included in a database study. The magnitude of surgical bleeding versus blood transfusion was analyzed to extract a subgroup of patients (n=982) in whom transfusions were independent from bleeding. Study II) PSB and venous-blood samples were collected from patients undergoing routine CABG (n=20). The in vitro capillary-flow properties of blood subcomponents and the effects of routine screen filtration were tested. PSB fat contamination was evaluated by imprint microscopy. Study III) Heat extracted liquid human fat or soya oil were mixed with mediastinal drain blood (n=20) and incubated in a temperature controlled column, to evaluate spontaneous density separation of fat. Study IV) The findings from study-III were applied to develop a fat-reducing system (FRS) using two stacked compartments. The FRS was experimentally tested (n=12), with similar methods as in study-III, and clinically evaluated (n=10). A single-chamber blood bag (n=10) served as reference. Results: Study I) A surgical bleeding of less than 400 mL showed no correlation to blood transfusion, although 64 of 982 patients still received allogeneic blood. The strongest predictors for this kind of transfusion were; female gender, weight ≤70 kg, CPB time ≥90 minutes, CPB temperature ≤32 ºC, and advanced age (P&lt;.001 - .038). Study II) The capillary-flow profile of PSB plasma was highly impaired compared to venous plasma (P&lt;.001). Conversely, blood-cell components showed no difference between PSB and venous blood. Routine screen filtration showed no ameliorating effect on capillary-flow resistance. Fat debris was detected on imprints in all PSB samples in contrast to venous plasma (P&lt;.05). Study III) After 10-min of incubation had 77% of added soya oil separated and found contained in the top 20% fraction of blood (P&lt;.001), aimed to be discarded. The density separation of human fat was less efficient compared to soya oil (P=.011). Fat also adsorbed to surface which was more pronounced at low temperature (P&lt;.001). The overall reduction of human fat was 70%. Study IV) PSB contained 1.5 mL fat suspended in 418 mL PSB. Of this fat was 24% surface-bound. Experimental analysis of the proposed FRS revealed an 83% fat-reduction which was clinically confirmed, suggesting 80% reduction (P=.001). The FRS also gave a small but significant erythrocyte-concentrating effect. Conclusions: Transfusion of allogeneic blood during CABG surgery appeared associated with an institutional, individual, and technical bias of an anticipated need and not only used to compensation for surgical bleeding. In part may this reflect a non-compliant CPB methodology and hemodilution. It was confirmed that PSB plasma contained fat, with a suggested embolic potential. Human fat was significantly reduced from mediastinal drain blood by spontaneous density separation and surface adsorption. The prototype FRS used for PSB incubation during CPB allowed an efficient fat reduction.

Bone grafts and titanium implants are commonly used for surgical/prosthetic rehabilitation of the atrophic edentulous maxilla. The factors which influence bone graft healing and implant integration are not sufficiently understood. The aim of this dissertation was to evaluate autogenous bone grafting and delayed placement of titanium endosteal implants for reconstruction of the atrophic maxilla, including the effects of different patient factors on bone graft healing and integration of titanium implants into grafted bone. A total of 46 patients with severe maxillary atrophy received onlay- (n=35) or interpositional bone grafts (n=11) and 6 mo. later received 341 titanium endosteal implants. All bone grafts were harvested from the iliac crest. All patients received fixed dental bridges and were followed clinically and with radiographical examinations for 3 yr. In Papers I and II, a total of 68 titanium microimplants were placed and retrieved from the bone grafts at various time points for histological analysis of the bone graft-implant interface. Integration was better after 6 mo. healing than placement in conjunction with bone grafting. Implant integration was similar for the two bone-grafting techniques. In Papers III and IV, originally including 29 patients and 222 implants, implant stability was measured with resonance frequency analysis (RFA) at placement, abutment connection, after 6 mo. of loading (III) and after 3 yr. of loading (IV). Ten non-grafted patients measured at the same time points were used as controls (III). RFA showed equal implant stability in grafted bone vs. non-grafted bone (III). Stability did not change from the 6-mo. to the 3-yr. control. Cumulative survival was 90% after 3 yr. (21 implants failed). Thirteen implants were lost prior to loading and 8 during functional loading. The group of failed implants showed a lower primary RFA stability than those that remained stable for 3 yr. All patients received and maintained a fixed dental bridge throughout the study. In Paper V, the graft volume changes (GVC) during the 6-mo. healing period prior to implant placement were studied in 30 patients using computerized tomography. Blood samples were taken from 25 patients in conjunction with bone grafting and were analysed for 13 haematological factors. Bone mineral density (BMD) was measured in 21 patients. Biopsies of the bone grafts were analysed for bone volume fraction (BVF). GVC (loss) was correlated with decreased BMD of the lumbar vertebrae L2-L4. There was no correlation between the haematological factors and GVC. Implant failure was not correlated with BMD, BVF or GVC. This dissertation shows that surgical/prosthetic rehabilitation of the atrophic edentulous maxilla with autogenous iliac crest bone grafts and delayed placement of titanium implants after 6 mo. of graft healing is effective, reproducible and functional. RFA at placement may be able to predict later implant failure.

The aims of the studies was to evaluate the short and long term effects on the development of parastomal hernia and stoma complications of a prophylactic prosthetic mesh placed in a sublay position at the index operation.  Also the purpose was to validate a definition of parastomal hernia at clinical examination and a method and a definition of parastomal hernia at CT-scan. In the first two studies 27 patients were randomized to a conventional stoma or to a stoma with the addition of a partly absorbable low weight large pore mesh in sublay position. Patients were examined after one and five years.  After five years the rate of parastomal hernia was 80% with a conventional stoma and 14% with the addition of a mesh.  A prophylactic mesh did not increase the rate of complications. In the third study a prophylactic mesh was intended at stoma formation in 93 consecutive patients in routine surgery. In 75 patients provided with a mesh the rate of parastomal hernia after one year was 13%. Complication rates were not increased in 19 severely contaminated wounds. In the fourth study 27 patients with ostomies were examined by tree surgeons and parastomal hernia was defined as any protrusion in the vicinity of the stoma. CT-scans with patients examined in the supine and prone positions were assessed by three radiologists. Herniation was then defined as any intra abdominal content protruding beyond peritoneum or the presence of a hernia sac. Kappa was 0.85 for surgeons and 0.85 for radiologists with CT-scan in the prone position. Kappa was 0.80 for surgeons and radiologists collectively, with CT-scan in the prone position. Four parastomal hernias detected at CT-scan in the prone position could not be detected in the supine position. A parastomal hernia diagnosed at clinical examination was always detected at CT-scan in the prone position. Conclusions: A prophylactic mesh placed in a sublay position at the index operation reduces the rate of parastomal hernia without increasing the rate of complications. Parastomal hernia should at clinical examination be defined as any protrusion in the vicinity of the stoma with the patient straining in the supine and erect positions.  At CT-scan, with the patient examined in the prone position, herniation should be defined as any intra abdominal content protruding beyond peritoneum or the presence of a hernia sac. / Embargo, publiceras 2011-05-01

Syfte: Syftet med denna litteraturstudie var att utifrån vetenskaplig litteratur beskriva patienters upplevelser av livskvalitet i samband med genomförd bariatrisk kirurgi utifrån aspekterna mental och fysisk hälsa, samt att granska och redovisa valda vetenskapliga artiklar. Metod: Författarna utförde en beskrivande litteraturstudie vilken baserades på 12 vetenskapliga artiklar. Eftersökningar utfördes på databaserna Cinahl, PubMed via Medline och Mosby´s index. Huvudresultat: Flertalet studier påvisade att övervikt och fetma påverkade deltagarnas upplevelser av livskvalitet på ett negativt sätt. Livskvalitetssänkande faktorer utgjordes av bl.a. brist på självförtroende, skamkänslor samt rädslor för följdproblematik. Bariatrisk kirurgi sågs för flertalet deltagare som en chans till förbättrad mental och fysisk hälsa, där exempelvis självförtroende, ett mer socialt aktivt liv och förbättrad rörelseförmåga var motiverande faktorer, vilka även förbättrade deltagarnas upplevelser av livskvalitet postoperativt. Trots flertalet positiva resultat, framkom även negativa upplevelser bland deltagarna. Negativa effekter, såsom smärta och kosmetiska defekter bidrog för dessa deltagare till försämrad upplevelse av livskvalitet. Slutsats: Bariatrisk kirurgi bidrog i de flesta fall till förbättrad mental och fysisk hälsa samt förbättrad upplevelse av livskvalitet i jämförelse med innan utförd kirurgi. För att uppnå fler resultat som skildrar patienters subjektiva upplevelser beskrivna med ord finns ett behov av vidare forskning av kvalitativ ansats. / Aim: The aim of this literature review was to by scientific articles describe patient’s experiences in conjunction with undergone bariatric surgery and to examine and report on selected scientific articles. Method: The authors performed a descriptive literature review that was based on 12 scientific articles research by databases Cinahl, PubMed through Medline and Mosby´s index. Main result: Several studies showed that overweight and morbid obesity had negative influence on the participant’s experience of quality of life. Factors that caused this experience were for example lack of self-esteem, feelings of shame and fears of consequential problems. Bariatric surgery were seen as a chance to improve mental and physical health, where self-esteem, a active social life and improved mobility were motivating factors that also improved the participant’s quality of life postoperative. Despite several positive outcomes, negative experiences were also revealed among the participants. Negative effects, such as pain and cosmetic defects, contributed for these participants to increased experiences of quality of life. Conclusion: Bariatric surgery in most cases contributes to improved mental and physical health and improved experiences of quality of life, then before undergone surgery. To achieve more results that in words, describes patient’s subjective experiences there is a need of further research with a qualitative approach.