M K ALAM MS; FRCS ALMAAREFA COLLEGE OF MEDICINE DAY SURGERY M K ALAM MS; FRCS ALMAAREFA COLLEGE OF MEDICINE

ILOs • Describe the benefits & problems of day surgery. At the end of this presentation students will be able to:   • Understand the definition of day surgery. • Describe the benefits & problems of day surgery. • Describe the types & the features of a desirable day-surgery unit. • Describe selection of suitable day-surgery procedure and patients. Describe the methods of assessing patients. 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 Problems: Benefits: Reduced cost. Initial cost of setting up units. Needs good organisation/ management. Resistance from medical staff. Morbidity from anaesthesia/ surgery Increased community care workload. Burden of care passed to family. Benefits: Reduced cost. High volume of patients. 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

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.

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 unsuitable 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 & 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 non-opioid 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!