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Poli.Chir. Ambulatory proctology Bruno Roche Unit of Proctology University Hospital of Geneva Bruno.Roche@hcuge.ch www.proctology.ch
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Poli.Chir. Advantages Life minimally disturbed Anxiety reduced Less nosocomial infections Earlier return to activities Work time off reduced
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Poli.Chir. Advantages Administrative management Costs of outpatient < inpatient Overall health expenditure reduced Hospital beds for severe cases
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Poli.Chir. Disadvantages Preoperative instructions Preoperative preparation difficulties Transportation problems Assistance at home Necessity of resuscitative back-up Analgesia management
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Poli.Chir. Selection criteria: Medical Age (no more) ASA I and ASA II (no more) Medical condition controlled No anti-aggregate medication
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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
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Poli.Chir. Selection criteria: General Not drive to go home Distance home hospital: 60 to 100 km Transportation facilities
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Poli.Chir. Selection criteria: Physician Emergency accessible 24 hours a day
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Poli.Chir. Anesthesia Local anesthesia Posterior perineal block Caudal or rachianesthesia General anesthesia Short duration Low side effects
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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
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Poli.Chir. Local anesthaesia and perineal block: 60 ml0.5% lidocaine + epinephrine 12 ml Natrium Bicarbonate 8,4 %
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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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Poli.Chir.
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Practical organisation The patients receives - Instructions postoperative care - Prescription - Appointment for day 5 Time needed: 60 to 90 minutes
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Poli.Chir. Postoperative management Sit Baths Shower: 3 - 6 x / D Topical wound healing cream: Mitosyl Panthenol Ialugen-Plus
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Poli.Chir. Postoperative management Laxatives: Mucillage Mineral oil Duphalac Anti-inflammatory drugs Painkillers
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Poli.Chir. Postoperative control On day 5 Weekly As necessary No routine digital examination Silver Nitrate if granulation
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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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Poli.Chir.
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Ambulatory procedure in L.A. 1993 to 2004 RECOVEREDAMBULATORY Haemorrhoids8871042 Fissures46545 Fistulas331686 Pylonidal Sinus16786 Condyloma37289 Tumours, polypes49175 Anoplasty1720 Others24182 Total14073725
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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
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Poli.Chir. Can we prevent postoperative complications Pain ? Bleeding ? Bladder Retention ? Fecal Impaction ?
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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
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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
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Poli.Chir. Prevention of urinary retention Operation with empty bladder Restriction of fluid administration Posterior Perineal Block < 0.5 %
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Poli.Chir. Prevention of faecal impaction Preoperative diet High fibbers rate Postoperative Paraffin oil daily Osmotic laxatives one week
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Poli.Chir. FUTURE: Quality control studies Evaluation the outcomes Assess patients satisfaction index If patients are not happy indications will never be enlarged
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Poli.Chir. Operative indications enlarged Rectoceles Sphincteroplasty
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Poli.Chir. Better Proct. outpatient surgery: Short anesthesia low of side effects Operative indications increase Overcome postoperative pain Stimulate wound healing
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Poli.Chir. Conclusions: Proctological outpatient surgery can be performed in a safe way: - few complications - high patient satisfaction index
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Poli.Chir. Indications will be enlarged if: General anesthesia shorter and safer Long lasting local anesthesia Better pain killers More effective wound healing drugs
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Poli.Chir. Indications will be enlarged if: Patient satisfaction index high Stimulation from insurances
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