1. Poli.Chir. Ambulatory proctology Bruno Roche Unit of Proctology University Hospital of Geneva Bruno.Roche@hcuge.ch www.proctology.ch

2. Poli.Chir. Advantages Life minimally disturbed Anxiety reduced Less nosocomial infections Earlier return to activities Work time off reduced

3. Poli.Chir. Advantages Administrative management Costs of outpatient < inpatient Overall health expenditure reduced Hospital beds for severe cases

4. Poli.Chir. Disadvantages Preoperative instructions Preoperative preparation difficulties Transportation problems Assistance at home Necessity of resuscitative back-up Analgesia management

5. Poli.Chir. Selection criteria: Medical Age (no more) ASA I and ASA II (no more) Medical condition controlled No anti-aggregate medication

6. Poli.Chir. Selection criteria: Social Positive for outpatient surgery Not alone during 24 hours Social circumstances adapted Easy access to a bathroom and toilets Telephone should be accessible

7. Poli.Chir. Selection criteria: General Not drive to go home Distance home hospital: 60 to 100 km Transportation facilities

8. Poli.Chir. Selection criteria: Physician Emergency accessible 24 hours a day

9. Poli.Chir. Anesthesia Local anesthesia Posterior perineal block Caudal or rachianesthesia General anesthesia Short duration Low side effects

10. Poli.Chir. Goals: - Deep and long-lasting analgesia - Relaxation of the anal canal - Blood-free operative field - No side effects on the bladder - Suppression of vagal reflex - Easy use in outpatients

11. Poli.Chir. Local anesthaesia and perineal block: 60 ml0.5% lidocaine + epinephrine 12 ml Natrium Bicarbonate 8,4 %

12. Poli.Chir. Practical organisation No starving No bowel preparation No depilation Premedication only for anxious people Empty bladder and rectum pre-op No venous access for LA and PPB Resuscitation material in the room

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14. Practical organisation The patients receives - Instructions postoperative care - Prescription - Appointment for day 5 Time needed: 60 to 90 minutes

15. Poli.Chir. Postoperative management Sit Baths Shower: 3 - 6 x / D Topical wound healing cream: Mitosyl Panthenol Ialugen-Plus

16. Poli.Chir. Postoperative management Laxatives: Mucillage Mineral oil Duphalac Anti-inflammatory drugs Painkillers

17. Poli.Chir. Postoperative control On day 5 Weekly As necessary No routine digital examination Silver Nitrate if granulation

18. Poli.Chir. Possible procedures: Thrombosed haemorroidectomy Haemorroidectomy Sphincterotomy Abscess drainage Fistulectomy Sliding flaps Anoplasty Anal warts excision Low located villous adenoma Sinus pilonidalis

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20. Ambulatory procedure in L.A. 1993 to 2004 RECOVEREDAMBULATORY Haemorrhoids8871042 Fissures46545 Fistulas331686 Pylonidal Sinus16786 Condyloma37289 Tumours, polypes49175 Anoplasty1720 Others24182 Total14073725

21. Poli.Chir. COMPLICATIONS OF 3725 PROCEDURES Bleeding (18) 4 post fistulectomy 8 post pylonidal sinus 5 post haemorrhoïdectomy 1 post sphincterotomy Infections0 Fecaloma3 Urinary Retention5 Hospitalisation17

22. Poli.Chir. Can we prevent postoperative complications Pain ? Bleeding ? Bladder Retention ? Fecal Impaction ?

23. Poli.Chir. Postoperative pain control We can’t determine preoperatively Tolerance of postoperative pain Sensitive person We should routinely : Infiltration long lasting AL Strong painkillers

24. Poli.Chir. Pre-emptive analgesia in post operative pain control Double blind randomised study Ropivacaïne vs. Placebo on 100 consecutive perineal surgery in general anaesthesia

25. Poli.Chir. Prevention of urinary retention Operation with empty bladder Restriction of fluid administration Posterior Perineal Block < 0.5 %

26. Poli.Chir. Prevention of faecal impaction Preoperative diet High fibbers rate Postoperative Paraffin oil daily Osmotic laxatives one week

27. Poli.Chir. FUTURE: Quality control studies Evaluation the outcomes Assess patients satisfaction index If patients are not happy indications will never be enlarged

28. Poli.Chir. Operative indications enlarged Rectoceles Sphincteroplasty

29. Poli.Chir. Better Proct. outpatient surgery: Short anesthesia low of side effects Operative indications increase Overcome postoperative pain Stimulate wound healing

30. Poli.Chir. Conclusions: Proctological outpatient surgery can be performed in a safe way: - few complications - high patient satisfaction index

31. Poli.Chir. Indications will be enlarged if: General anesthesia shorter and safer Long lasting local anesthesia Better pain killers More effective wound healing drugs

32. Poli.Chir. Indications will be enlarged if: Patient satisfaction index high Stimulation from insurances