Diving after Surgery

Surgery and Diving

By Dr Mike Marshall

Doctor, when can I dive again?

This is a question we get asked quite often asDAN DivingMedical Officers. However, a common question does not mean a simple answer.“When can I dive again after my operation?” is not simply a surgical matter, nor is it purely a diving medical one. Like so many things in medicine–it depends! There are several factors to consider whenever assessing fitness to dive after surgery. So, this article will attempt to offer a framework to assist both the doctor and the diver in taking them into consideration when making the decision.

John Dewey,US educator [s1] and proponent of the school of pragmatic thought, is quoted as saying “a problem well-defined is a problem half solved.” The proposed framework for deciding on a patient’s fitness to resume scuba diving after surgery is based on this idea. By asking a number of pertinent questions the post-surgical patient’s dive readiness can be better defined.

What was the indication for the surgery?

The first step in this decision-making process is to identify what the indication was for the surgery.Obviously, not all surgery is the same. An operation might be an emergency- or an elective procedure. The surgery can be extensive or minor.Any number of tissues or organs of the body may be involved.So, every case is taken on its own merits. For example: A patient with lung cancer may receive a thoracotomy and pneumonectomy procedure (i.e., opening of the chest cavity and excision of a lung) to remove the lung tumour. The surgery itself will result in reduced effort-tolerance and predispose the individual to potential air-trapping–both of which have significant safety implications for scuba diving. However, the primary indication or diagnosis for the surgery should not be overlooked– lung cancer. The chances are high that the person was already in poor general health, and there is a probable need for additional medical management (e.g., chemotherapy or radiation),all of which must be factored into the decision. On the other hand, plating a fractured forearm bone will pose a temporary interruption to scuba diving, but once the fracture has healed the original indication for orthopaedic surgery is of little further concern to the diver.

Is the indication for surgery a contra-indication to scuba diving?

The second step is to ascertain whether the reason for the surgery may also be a reason not to scuba dive: Significant coronary artery disease (requiring bypass grafting)is a potential reason not to scuba dive. Conversely, ahallux valgus, requiring “bunion surgery”,would not be a contra-indication to dive. Importantly, diving fitness may be affected significantly by the indication for surgery as well as the outcome of the surgery: Underlying osteoarthritis of a knee,leading to joint-replacement surgery, might affect a diver’s ability to fin, or even get on and off a boat initially. Some difficulty may remain after the surgical repair. Thus, the importance of this question may become even more evidentby asking the next one.

Has the indication for surgery been completely resolved by the operation?

Essentially, the question is this –is the problem solved now? This is a vital step in this decision-making process. Has the surgery resolved the problem that prompted it? An appendicectomy for a septic appendix is typically completely curative; it should not limit future scuba diving. Similarly, surgical repair of a perforation of the eardrum could allow a diver to return to the water, but only once the ENT surgeon has confirmed the ear-drum has healed and normal middle-ear equalising has recovered. Conversely, surgery for a herniated lumbar disc with related nerve root damage may produce restricted movement in the lower back without resolving all the nerve impairment. Such residual problems might limit future scuba diving.

What restrictions remain from the indication for surgery?

Obviously, all surgery is not curative. Residual restrictions might limit a diver’s return to the sport. For instance, a craniotomy (i.e., opening of the skull by removal of some of the cranial vault) for the removal of a traumatic brain haemorrhage is usually an absolute contra-indication for future scuba diving. In addition to the original damage caused by the traumatic injury to the brain, and the impact of the subsequent surgery, there is another concern: a significant risk of post-traumatic epilepsy. Often, the chances of a seizure have the greatest impact on future diving safety. In other words, it is not always the indication for surgery, nor even the operation itself, that may have the greatest impact on fitness to dive. It may ultimately be the unpredictable consequences of having had the surgery. By comparison, a below-knee amputation (e.g., following a severe crush injury of the lower limb)produces significant, permanent, physical limitations. But these are fixed disabilities and they can be addressed and overcome with a suitable prosthesis, which means that it should not stop the diver from returning to the sport once the necessary accommodations have been made.

Were there any surgical complications that might restrict a return to diving?

Surgical complications can be classed as either short- or long-term:Short-term complications include blood-loss anaemia, infection and loss of function. Anaemia can reduce divers’ exercise capacity and will delay their return to the sport. Similarly, an infection at the surgical site will postpone recovery. Loss of function, a common feature of many orthopaedic procedures (e.g., fracture fixation and joint replacement), will also delay diving for a while.These are all short-term problems, however. Long-term surgical complications may be more problematic: These include post-operative stroke; residual impairments due to a heart attack; or kidney insufficiency. These will obviously restrict and may even defer future scuba diving indefinitely. Proven air-trapping in the lungs (e.g., as a complication of a thoracotomy)introduces an unacceptable risk of pulmonary barotrauma; as such it will preclude return to diving. A post-operative abdominal hernia, in which the bowel protrudes between the muscles of the abdomen, also represents a long-term contra-indication to diving. The difference is that it can be surgically corrected.

While not strictly complications of surgery, there are a few additional surgical implications that must also be considered when making a “fitness to dive” decision. Having a splenectomy (i.e., removal of the spleen) impairs one’s defences against certain infections. Diving in remote locations, where access to appropriate medical attention may be difficult, should probably not be contemplated by divers who have had their spleens removed. Another example –stapedectomy (i.e., an operation to replace the stapes bone in the middle ear with a prosthetic piston) –was considered an absolute contra-indication to scuba diving in previous years. This trend has changed, but reliable equalisation – without vertigo –must first be confirmed by an ENT specialist. Loss of the vocal cords (e.g., due to surgery fora laryngeal tumour) may affect a diver’s ability to perform a Valsalva manoeuvre, whereas a tracheostomy (i.e., open breathing hole in the neck), would be completely incompatible with diving.

Recovery from surgery also implies a recovery from the anaesthetic and the withdrawal of sedating analgesics (i.e., pain killers). Hypoxic brain injury after a complicated anaesthesia may impair a patient’s ability to perform even his normal activities of daily living, let alone scuba diving. Even in the absence of any anaesthetic complications, a general anaesthetic should prompt a delay of at least 24–48 hours before diving. Surgical implications and sedating post-surgical analgesics, such as opioid analgesics, would extend this prohibition.

If any implants or devices were left in situ, will their presence restrict diving?

As a rule, an implant that does not contain air should not impose any limitation on scuba diving. Metallic joint prostheses and silicone breast implants are not compressible, so they do not pose any implosive or explosive danger to a diver. There may be buoyancy implications to consider, however. External devices are more likely to be affected: In addition to the effects of being immersed, an external  hollow prosthetic limb is also subject to the effects of Boyle’s Law; it may therefore be at risk of being damaged by changes in pressure. Also, implants that breech physiological barriers such as grommets in the ear drum or long-term intravenous ports (e.g., Hickman lines) are potential sources of infection and malfunction. Grommet surgery for a chronic middle-ear infection also introduces the risk of caloric vertigo, by introducing water into the middle-ear when the diver descends. Diving should be delayed until they are expelled and ear equalisation is fully restored, which takes between 4–12 months.  

Has the surgical wound healed?

As obvious as this may seem, the surgical skin incision should be healed before returning to diving.However, surgeons do not necessarily share the same criteria for determining when a wound has healed sufficiently for immersion in water. Typically, the concern is about infection or dehiscence (i.e., splitting open). Maceration (i.e., water-logging) of a surgical scar may predispose both of these problems. A general rule of thumb is to wait for at least 2–3 weeks before returning to diving after surgery – when the wound no longer requires any sort of dressing. Some surgeons may advise a longer period of waiting, especially when the surgery has been cosmetic and the appearance of the scar is an important consideration: Applying stresses across an “immature” wound (by doing physical activity prematurely)increases the risk of developing an unsightly scar. Stresses of physical activity, like carrying heavy dive gear, may increase the risks of dehiscence of the superficial or deeper tissues involved in the surgery.A fractured bone takes some weeks to heal. Proof of this healing should be confirmed on x-ray before a return to diving is advisable. Similarly, bowel function can take several weeks to return to normal after abdominal surgery. This should be confirmed by the surgeon before the diver returns to the water.On a related note: It is possible to dive with a colostomy once it has healed and if the underlying condition is not a contra-indication to diving.

Has the patient returned to full strength and fitness following the surgery?

Most operations result in some degree of general loss of effort tolerance. Whether due to a period of forced bed-rest, post-operative anaemia, prescribed medication or other causes, this reduced ability to exercise must be factored into a fitness to dive decision. In addition, there may be some local weakness following surgery: Weak abdominal muscles, following abdominal surgery, result in a weak core which will impair a diver’s ability to carry heavy gear. Similarly, orthopaedic surgery on a limb typically produces some degree of weakness and a restriction on the range of motion. It is helpful to be reminded that, functionally speaking, scuba divers carry between 30–40kg of gear and are usually required to make rather abrupt and ungainly entries and exits from the water. Range of movement and strength deficits should be viewed in relation to these functional requirements. Divers should therefore be rehabilitated and recover functional fitness before resuming scuba diving.Specific rehabilitation regimens may also apply to certain conditions: Surgery for coronary artery disease, whether the artery is bypass grafted or stented (i.e., a tube implanted in the heart artery to maintain its patency), must be followed by a gradually progressive cardiac rehabilitation program. Only when the patient can perform appropriate exercise, without any symptoms or changes on ECG, can they be considered fit to dive.

Is the patient using any medication that is unsafe with diving?

This topic has been discussed extensively in previous Alert Diver articles and we refer our readers to them.Suffice to say that the prescription of sedating analgesics is common after surgery and incompatible with diving. Therefore, these medicines must be considered when deciding about a diver’s fitness to dive.

Are any adaptations in dive gear or dive protocols required?

There is no single standard of being fit to dive. People with disabilities can scuba dive if the necessary modifications to equipment and procedures are made to ensure their safety. Similarly, post-operative patients may require some changes in their diving activities to be able to dive safely. An amputee can dive as long as their support is appropriate. Many divers with disabilities can dive as long as they have at least two physically unimpaired buddies to support them underwater, and water entries and exits are well-planned. Even following brain surgery, a diver might be considered fit to do supervised, depth-limited dives e.g., in an aquarium while using a helmet breathing system to mitigate the risk of drowning if they develop a seizure.

The last word

It should be clear that there is no one, easy answer to returning to diving after surgery. Rather, there are several issues that must be considered. Also, it is clear that the process of answering these issues, and thereby defining a person’s fitness to resume scuba diving, must be a consultative process. This process must–at least–include the surgeon involved; aDive Medical Officer / Examiner; sometimes a physio therapist or biokineticist; and– always –the diver! Together, they will be far better able to offer a sensible and safe answer to the question: “Doc, when can I dive again?”.

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