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Formulas and Surgical Procedures

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by Dr. Skylar Stumpf DTCM, LAcon August 07, 2025

Surgery, while a critical intervention for many health conditions, inevitably disrupts the body’s homeostasis and initiates a cascade of inflammatory and physiological changes. Common postoperative complaints like pain, fatigue, gastrointestinal issues, infections, and anxiety have become focal points for integrating modern biomedical practices with Traditional Chinese Medicine (TCM). Recent research strongly supports the effectiveness of integrative approaches, particularly acupuncture and herbal medicine, in optimizing postoperative recovery and enhancing overall patient resilience.

Traditional Chinese Herbal Medicine for Perioperative Pain Management

Managing pain and discomfort around surgical and medical procedures is a critical aspect of patient care. While modern medicine often relies on opioids, NSAIDs, and regional anesthesia for perioperative pain control, there is growing interest in complementary approaches to enhance recovery and reduce side effects (especially in light of the opioid crisis) (pubmed.ncbi.nlm.nih.gov).

Traditional Chinese Medicine (TCM) offers a rich history of herbal remedies and therapies that have been used for pain relief for thousands of years. Increasingly, clinical research is examining how Chinese herbal medicine – whether as formulas, individual herbs, or topical preparations – can complement standard care in preoperative and postoperative settings. This article provides a general review of TCM herbal medicine in managing pain and discomfort before and after common procedures, drawing on human clinical trials, animal studies, and historical practices. Key mechanisms of action (e.g. anti-inflammatory, analgesic, and immunomodulatory effects) are discussed, along with examples of commonly used herbs/formulas, their applications, and safety considerations in the perioperative context.

Historical Context of TCM in Surgical Care

Traditional Chinese medicine has long recognized the challenge of pain and devised strategies to manage it even in eras before modern anesthesia or analgesics. One famous example is Hua Tuo (c. 140–208 CE), a legendary physician-surgeon credited as the first in China to use general anesthesia in surgery. Hua Tuo created a wine-based herbal anesthetic called Mafeisan (“cannabis boil powder”) which reportedly induced insensitivity to pain during major operations. This early use of an herbal general anesthetic underscores that Chinese herbs have been involved in perioperative care for centuries. In traditional trauma medicine, numerous herbal formulas were developed to treat injuries, reduce pain, and speed healing. For example, topical tinctures and plasters known as “Die Da Jiu” (“hit-and-fall wine”) were commonly applied to bruises or fractures to alleviate pain and inflammation (see Great Mender).

In the early 20th century, during a time of war and limited access to modern medicine, Chinese herbalists continued to innovate. Yunnan Baiyao is a notable TCM formula invented in 1902 by Dr. Qu Huangzhang, initially kept as a proprietary remedy (pmc.ncbi.nlm.nih.gov). Yunnan Baiyao gained fame for its ability to stop bleeding, reduce swelling, and relieve pain in traumatic injuries. It was so effective in treating battlefield wounds that it was widely distributed to soldiers during the Sino-Japanese War, becoming “indispensable” for the wounded. Over time, Yunnan Baiyao entered mainstream use in China for surgical bleeding and postoperative recovery. These historical anecdotes illustrate a consistent theme: TCM practitioners have long addressed perioperative or injury-related pain using herbal means, whether through systemic remedies taken by mouth or external applications.

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Mechanisms of Action of Chinese Herbal Analgesics

Traditional Chinese medicine attributes perioperative pain to disruptions in the flow of Qi and Blood, often caused by trauma, surgical intervention, or the invasion of pathogenic factors (such as Cold, Wind, or Stasis) (mdpi.com). The TCM approach to pain is to “reinforce the healthy Qi and eliminate the pathogenic factors”, thereby restoring balance and alleviating pain. In practice, this means herbal formulas are designed either to tonify deficiencies (boosting the body’s resilience) or to remove obstructions like blood stasis and inflammation that cause pain. For example, pain accompanied by swelling and bruising might be treated with herbs that activate blood circulation and reduce stasis (to resolve hematomas), whereas pain from cold obstruction might be treated with warming, circulation-promoting herbs.

Modern pharmacological research has begun to elucidate the biological mechanisms behind these traditional concepts. Notably, scientists have identified over 800 herbal substances in the Chinese materia medica with analgesic or pain-modulating properties (pubmed.ncbi.nlm.nih.gov).

Many Chinese herbs contain bioactive compounds that exhibit anti-inflammatory effects (reducing production of prostaglandins and cytokines), analgesic effects (acting on neural pain pathways or receptors), and immunomodulatory effects (supporting tissue repair and reducing swelling).

The mechanisms are often multifactorial, with herbs influencing neurotransmitter receptors, modulating inflammatory mediator release, and even inhibiting pain-related enzymes (nature.com). For instance, the tuber Yan Hu Suo (Corydalis yanhusuo) is rich in alkaloids like dehydrocorybulbine (DHCB) that can relieve pain. Studies show Corydalis extracts effectively attenuate acute, inflammatory, and neuropathic pain in animal models without causing tolerance (a key advantage over opioids) (pmc.ncbi.nlm.nih.gov).

These alkaloids are thought to act on dopamine D2 receptors and possibly on central opioid receptors, producing analgesia and mild sedative effects. Another example is Aconitum (Fu Zi, Cao Wu), an herb historically used for severe pain due to its potent analgesic alkaloids. Aconitine-type alkaloids from Aconitum can block nerve signal transmission (voltage-gated sodium channels), thereby deadening pain sensation – though they must be processed to reduce toxicity (pmc.ncbi.nlm.nih.gov). Many herbs also have antioxidant properties that mitigate tissue damage, and some promote microcirculation (enhancing oxygen delivery to tissues), which can hasten recovery and indirectly reduce pain. In summary, TCM herbs work through a combination of analgesic, anti-inflammatory, circulatory, and neuromodulatory mechanisms, aligning well with the needs of perioperative care.

Preoperative Use of Chinese Herbal Medicine

Preoperative phase interventions with Chinese herbal medicine can serve two main purposes: (1) to optimize the patient’s condition before surgery (e.g. improving vitality, immunity, or specific organ function), and (2) to alleviate pre-surgical symptoms such as pain or anxiety. In TCM practice, it is not uncommon to give tonifying herbal formulas in the weeks leading up to an operation, tailored to the patient’s constitution. For example, a patient with underlying Qi and Blood deficiency might receive Free and Easy Wanderer (Xiao Yao San) or Women’s Precious (Ba Zhen Tang) to strengthen their core health status and possibly improve wound healing capacity. Similarly, someone prone to poor circulation might be given mild blood-activating herbs (unless contraindicated) to reduce the risk of postoperative blood stasis pain. While these traditional practices are based on theory and empirical use, formal clinical trials are limited. However, some modern research supports the idea that preoperative herbal therapy can enhance readiness and recovery. For instance, a recent randomized controlled trial in 2023 tested a “synergistic multimodal TCM supplement” in surgical patients, with dosing beginning 3 days preoperatively and continuing post-op (pubmed.ncbi.nlm.nih.gov). The herbal supplement (a combination of several pain-relieving and tonifying herbs) was well tolerated and, notably, patients receiving it reported significantly faster pain reduction after surgery compared to placebo – three times faster by one analysis. By post-op day 5, pain levels in the TCM group were four-fold lower than in the control group despite similar use of conventional pain pills. This suggests that certain herbal formulations given before and around the time of surgery can confer preemptive analgesic benefits and improve postoperative comfort. In addition, the TCM-treated patients in that study had better sleep during recovery, an important aspect of preoperative anxiety relief and healing.

Another area of interest is herbal anxiolytics for pre-surgical anxiety. Anxiety can exacerbate pain perception and complicate anesthesia management. Instead of (or alongside) benzodiazepines, some researchers have explored TCM alternatives. A notable example is the Japanese Kampo formula Yokukansan (Yi Gan San--a variant of Xiao Yao San), traditionally used to calm the spirit. Yi Gan San has demonstrated sedative and anxiolytic effects in perioperative settings – one trial found it produced better preoperative sedation than diazepam in patients undergoing colon surgery (researchgate.net). Yi Gan San's active constituents modulate neurotransmitters such as GABA and glutamate, which likely explains its calming properties. In addition to reducing anxiety, Yi Gan San and similar formulas may have direct analgesic effects: preclinical studies show Yi Gan San alleviates neuropathic and inflammatory pain in animals. A pilot clinical study in dental surgery patients (mandibular third molar extraction) found that administering Yi Gan San before the procedure helped reduce postoperative pain and improve patient comfort, particularly in those with high anxiety. These findings point toward a dual benefit of certain herbal preparations in the pre-op period: calming the patient and potentially providing preemptive analgesia.

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An Important Consideration Prior to Using Herbal Formulas Near Procedures:

Surgical procedures place the body under significant physiological stress, and the use of herbs or dietary supplements during this time can have important implications for safety and surgical outcomes. According to the Mayo Clinic’s SPAQI surgical guidelines, several commonly used herbal supplements, including those found in Traditional Chinese Medicine (TCM), may increase perioperative risk—particularly through effects on bleeding, sedation, or drug metabolism.

Supplements That May Affect Bleeding Risk

A wide range of herbs and supplements may inhibit platelet function or coagulation and should ideally be discontinued two weeks prior to surgery. These include:

  • Aloe, Arnica, Boldo, Bromelain, Cat’s Claw, Danshen, Devil’s Claw, Dong Quai, Evodia, Fenugreek, Feverfew, Garlic, Ginger, Ginkgo, Ginseng (American, Panax, Siberian), Guarana, Horse Chestnut, Policosanol, Resveratrol, Saw Palmetto, Turmeric, Vanadium, and Vitamin E.

These agents may alter metabolism or clearance in ways that are not predictable and increase the risk of perioperative bleeding.

Additionally:

  • Chondroitin and Glucosamine should be held for 48 hours prior to surgery due to a shorter half-life and more rapid clearance.
  • Black Tea Extract may increase bleeding risk and should be discontinued two weeks before surgery, or the dose tapered in the days leading up to the procedure. However, black tea as a beverage is considered safe up to the day of surgery.
  • Green Tea Extract, while potentially increasing bleeding risk, is not required to be held, as its catechins may offer cardiovascular benefits, such as improved diastolic function.
  • Fish Oil and Omega-3 Fatty Acid preparations do not need to be discontinued, as prospective studies have not shown an increased bleeding risk.

Herbs Affecting Anesthesia and Sedation

Some herbs can interact with anesthetic agents or increase sedation:

  • Valerian and Kava Kava enhance GABAergic sedation and may prolong anesthesia effects.
  • St. John’s Wort induces cytochrome P450 enzymes (especially CYP3A4), which may interfere with the metabolism of anesthetics and other perioperative medications.

The Mayo Clinic guidelines recommend discontinuing these herbs two weeks before surgery to minimize the risk of excessive sedation or altered drug metabolism.

Supplements with Immunologic or Metabolic Effects

  • Echinacea may pose a risk in patients undergoing immunosuppression and may interfere with liver enzyme systems.
  • Vitamin C in very large doses (>2,000 mg/day) may interfere with lab testing and contribute to oxalate accumulation in the kidneys.

TCM Formulas Worth Reassessing Pre-Surgery:

Some traditional Chinese herbal formulas also contain ingredients that activate blood circulation or may influence coagulation, making them potentially contraindicated preoperatively:

  • Yunnan Baiyao, though renowned for controlling bleeding in traumatic injuries and used intraoperatively in China, should still be used with caution in the pre-op period without professional guidance, as it contains potent bioactive compounds.
  • Xue Fu Zhu Yu Tang and other Blood-activating formulas (e.g., containing Tao Ren, Hong Hua) are commonly used for pain or stasis but may pose a bleeding risk and are typically paused 3–5 days before surgery.
  • Yan Hu Suo (Corydalis yanhusuo), known for its powerful analgesic properties, contains alkaloids with potential sedative and antiplatelet actions—not recommended just prior to procedures.
  • Fu Zi (Aconitum), found in some pain formulas, must be strictly avoided preoperatively due to its potent alkaloid content and potential effects upon cardiac tissue.

Clinical Recommendation:

In the weeks prior to surgery, individualized review of all herbal medications and supplements should be conducted. TCM practitioners and biomedical providers must collaborate to temporarily modify or pause herbal interventions where necessary, especially those with:

  • Anticoagulant or antiplatelet properties
  • Sedative or hepatic enzyme-inducing effects
  • Cardiotoxic or neuroactive ingredients

Ensuring a clear window without such agents minimizes intraoperative risks and improves patient safety. When appropriate, gentle, tonifying herbs with minimal drug interaction profiles, such as Huang Qi, or Ba Zhen Tang, may be continued under supervision to support recovery preparation.

By carefully navigating the timing and selection of herbal therapies, practitioners can uphold both the safety and integrity of integrative perioperative care.

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Addressing Barriers to Recovery:

From a biomedical standpoint, surgical procedures trigger significant inflammatory responses mediated by cytokines and prostaglandins, essential for healing but also responsible for discomfort and complications such as pain, fatigue, and nausea. Surgical trauma and medications can also slow gastrointestinal motility, leading to postoperative ileus, as frequently seen in colorectal surgeries. A study by Wang et al. demonstrated electroacupuncture's efficacy in reducing postoperative ileus by promoting faster recovery of bowel function, underlining acupuncture’s potential in managing postoperative gastrointestinal disturbances.

In TCM, surgery is understood as a profound disruption of Qi and Blood circulation. This disruption often results in patterns such as Qi stagnation, Blood stasis, and deficiencies in the Spleen, Liver, and Kidney organ-networks. These imbalances correspond closely with biomedical inflammatory and metabolic disruptions, emphasizing the necessity of integrative strategies for optimal recovery.

The postoperative period is where Chinese herbal medicine has perhaps the most to offer as an adjunct to conventional pain management. After surgery, patients often experience pain from tissue trauma, inflammation, and nerve irritation, typically managed with opioids or NSAIDs. TCM approaches this scenario by using herbs/formulas that reduce inflammation, improve circulation (to prevent blood stasis), and directly alleviate pain. Clinical evidence is increasingly supporting the benefits of integrating Chinese herbs in postoperative care. A landmark Phase I/II placebo-controlled trial in the United States (cited earlier) demonstrated that patients who took a multi-herb TCM supplement for 5 days post-surgery (in addition to standard analgesics) recovered faster from pain than those on standard care alone. By the end of the first postoperative week, subjective pain ratings were significantly lower in the TCM group, even though both groups had access to the same pain medications. Importantly, this trial found no increase in adverse effects with the herbal supplement – patients tolerated it well (pubmed.ncbi.nlm.nih.gov). Such evidence aligns with the idea that Chinese herbs can amplify pain relief (perhaps by anti-inflammatory action or mild intrinsic analgesia) without necessarily replacing conventional drugs (as opioid usage did not differ between groups).

Pain and anxiety significantly impact postoperative recovery. The research by Ben‐Arye et al. on gynecological oncology surgeries highlighted how preoperative relaxation techniques combined with intraoperative acupuncture significantly reduced postoperative pain and anxiety. From a TCM perspective, acupuncture works by unblocking stagnant Qi and invigorating Blood flow, essential for managing pain and anxiety.

Pivoting to a common consideration in the clinic: gynecological surgery. Postoperative uterine cramping (for example, after procedures like dilation & curettage or after fibroid removal). A randomized trial in 2020 in Taiwan investigated an herbal formula for post-D&C cramping and found it reduced the need for additional analgesics compared to placebo (though details are beyond our scope here). The principles remain consistent: tonify where there is deficiency and move blood where there is stasis to relieve pain. Herbs like Yi Mu Cao (Leonurus japonicus), known as “benefit mother herb,” are frequently used postpartum and post-gynecologic surgery to contract the uterus gently and alleviate pain while promoting healing of the endometrium. Safety considerations in breastfeeding women are also important – fortunately many TCM postpartum herbs like Dang Gui and astragalus are considered safe during lactation, and the above systematic review noted no significant adverse effects in mothers or infants (mdpi.com).

Postoperative ileus represents a critical challenge, particularly after abdominal surgeries. Electroacupuncture has shown particular promise here, with studies conducted by Wang et al. and Yang et al. confirming its effectiveness in reducing the duration of postoperative ileus. Acupuncture at points such as ST36 (Zusanli) significantly enhances bowel motility by stimulating gastrointestinal hormones and improving local and systemic inflammation.

Incorporating dietary strategies and gentle physical activities, alongside acupuncture, further enhances recovery. A diet emphasizing easily digestible, nutrient-dense foods, coupled with herbs that support digestive Qi such as ginger and peppermint, can significantly improve gastrointestinal function postoperatively.

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Infections remain a critical postoperative risk. Biomedical practices emphasize antibiotics and wound care, while TCM contributes significantly with herbal remedies. Herbs like Scutellaria (Huang Qin) and Honeysuckle (Jin Yin Hua) possess documented antibacterial properties, supporting biomedical interventions by reducing inflammation and enhancing immune response. Integrative use of probiotics and immune-enhancing herbal preparations is particularly beneficial in preventing infections and supporting systemic recovery.

Effective integrative care begins preoperatively. Implementing preoperative acupuncture sessions, as shown in the research by Ben‐Arye and Usichenko, helps minimize surgical stress, pain, and anxiety. Nutritional optimization, including the use of anti-inflammatory foods and adaptogenic herbs fortifies the body’s resilience to surgical stress. Mind-body practices such as guided imagery and mindfulness meditation significantly reduce stress-induced inflammation, positively affecting recovery trajectories.

Patient education remains essential, empowering individuals to actively participate in their recovery through informed dietary choices, gentle exercises, and early mobilization practices. Encouraging self-administered acupressure on specific points known for alleviating pain and digestive discomfort (e.g., LI4, PC6, ST36) complements professional treatments.

Integrating TCM and biomedical approaches provides a comprehensive model of postoperative care, addressing both physiological and energetic dimensions of recovery. Emerging research consistently supports this integration, confirming that acupuncture and herbal medicine significantly enhance recovery outcomes. As evidence grows, healthcare practitioners have the opportunity—and indeed the responsibility—to incorporate these complementary therapies routinely.

Ultimately, embracing an integrative approach ensures holistic patient care, improved postoperative outcomes, reduced recovery times, and enhanced patient wellbeing.

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