DAY SURGERY
M K ALAM MS; FRCS
ALMAAREFA COLLEGE OF MEDICINE
ILOs
At the end of this presentation students will be able to:
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Understand the definition of day surgery.
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Describe the benefits & problems of day surgery.
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Describe the types & the features of a desirable day-surgery unit.
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Describe selection of suitable day-surgery procedure and patients.
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Describe the methods of assessing patients.
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Choose appropriate anaesthesia and analgesia
•
Describe discharge criteria
Definition
• Ambulatory surgery: Surgery performed on a day-case basis
• North America: 23 hours overnight stay
• UK & Europe: Admission & discharge on the day of surgery
• Our practice: Admission 6.30 AM,
Observed 4-8 hours post-operatively
Discharged usually before 8PM.
Introduction
• Increasingly important part of elective surgery
• 50% of elective surgery in UK
• >60% in USA and Canada
• Patients particularly children prefer it.
• Quality of care should be same as in-patient.
• Surgical outcome sometimes better than inpatient.
Benefits and problems
• Benefits:
• Problems:
• Reduced cost.
• Initial cost of setting up units.
• High volume of patients.
• Needs good organisation/
• Reduced waiting list.
• In-patient beds freed for major
surgery / emergencies.
• Reduced DVT/ HAI*.
• Minimal disruption to patient’s life.
• Early return to work.
• Patients / children prefer it.
* Hospital acquired infections
management.
• Resistance from medical staff.
• Morbidity from anaesthesia/
surgery
• Increased community care
workload.
• Burden of care passed to family.
Types of day-surgery facilities
• Free- standing units built within community. Lack
overnight facilities. Patients unable to be safely
discharged needs ambulance transfer to a hospital
• Hospital integrated units in a dedicated day ward.
Separate or part of existing theatre complex.
• Most day surgery units use specialized day surgery
trolleys instead of beds.
Desirable features of a day-surgery unit
• Self contained ( reception, ward, theatre, and recovery area).
• Adjacent parking.
• Well laid out- good patient flow.
• Equipped to the same high standard as in-patient facilities.
• Protocols for selection, analgesia and discharge criteria.
• Good record keeping
• Support services readily available.
• Trained and experienced staff.
• Training and supervision
• Team work between staff groups
• Liaison with community services.
Criteria for suitable day-case procedures
• Minimal physiological disturbance.
• No excessive blood/ fluid loss.
• Very low risk of postoperative bleeding/airway problems.
• Duration 1-2 hours(maximum).
• Pain controllable with oral analgesia after discharge.
• Patient reasonably ambulant afterwards.
Suitable day-surgery procedures in General surgery
• Superficial lumps: Lipoma, sebaceous cyst etc.
• Breast lumps: Excision, excision biopsy, gynaecomastia.
• Varicose veins: Ligation, stripping, avulsions.
• Hernia repair: Inguinal, femoral, PUH, small incisional.
• Anal procedures: Lateral internal sphincterotomy, band ligation,
sclerosant injection, haemorrhoidectomy
• Laparoscopic cholecystectomy ( personal series > 400 cases)
Selection criteria for GA (adult day-surgery)
• A responsible adult to escort patient home.
• A responsible adult to supervise & care patient home.
• Patient living at a reasonable distance from health facility (1 hour).
• Reasonable home circumstances- telephone, stairs, heating/cooling, toilet.
• Patient fit and ambulant.
• Patient not grossly obese (BMI < 35).
• Patient able to climb one flight of stairs.
Patients not selected for day-surgery
• CVS disease: Poorly controlled hypertension,, angina, CCF,MI, TIA within 6
months, symptomatic valvular disease, cardiomyopathy.
• Respiratory disease: Severe asthma, COPD.
• Diabetes: Poorly controlled, IDDM.
• CRF, CLD.
• Addicts: Narcotics, alcohol.
• Psychiatric illness, MS, severe cervical spondylosis
• Medications: Anticoagulants, steroids, GTN, digoxin, MAOI, antidysrythmics,
American Society of Anesthesiologist (ASA) classification
• ASA 1: A healthy patient
• ASA 2: Mild systemic disease, no functional limitation.
• ASA 3: Severe systemic disease, some functional limitation.
• ASA 4: Sever systemic disease, constant threat to life.
• ASA 5: Moribund patient, not expected to survive next 24 hours.
* ASA 1,2 and some ASA3- suitable for day-surgery.
Methods of assessing patients
• SOPD (History, examination, investigation, diagnosis)
• Pre-assessments: (surgeon,& anesthetist) Consultation,
appropriate investigation, answer patient questions.
Written information- admission, operation and discharge.
• Day surgery waiting list.
Admission for surgery
• Patients arrive fully prepared (GA-NPO from midnight).
• Quick reassessment for any new problem.
• Consent for surgery if not already signed.
• Operation site marked.
• Early on the operation list for to allow enough
recovery time from GA. (1st or 2nd – my practice).
• LA cases- can be later on the list.
Anaesthesia and analgesia
• GA, LA, RA
• Newer techniques in GA: Total iv anaesthesia
(TIVA) with propofol infusion, sevoflurane, use of
laryngeal mask- more rapid recovery.
• Pre-operative (1 hour)- oral NSAID or paracetamol
(effective post-operative analgesia and reduced requirement of narcotics).
• Postoperative: IV paracetamol
Recovery
• Main problem: Postoperative pain, nausea & vomiting
• Postoperative pain:
Moderate- oral paracetamol, NSAID.
Sever- short acting opiate(fentanyl).
• Postoperative nausea/ vomiting:
General measures- short-acting anaesthetic, preoperative nonopioid analgesia, minimizing fast time & preoperative IV fluid.
High risk patient- ondansetron with dexamethasone4-8 mg
Discharge criteria
• Postoperative: Visit by surgeon/anesthetist desirable.
• Stable vital sign.
• Well oriented patient.
• Pain controlled & analgesics supplied.
• Minimal nausea or vomiting.
• No bleeding from the wound.
• Responsible adult to take home & care for 24 hours.
Written information on discharge
• Medication.
• Wound care.
• Bathing.
• Return to normal activity.
• Sign & symptoms indicating a problem.
• Emergency telephone contact number.
• Follow-up arrangements.
Thank you!