Principles of surgery. Day case surgery is a rapidly evolving surgical sub speciality that seeks to eliminate the need for prolonged admission in surgical patients and the attendant complications of prolonged immobilization. It is based on the documented evidence that most post op patients does not require specialised post op care and hence can be allowed to recover at home. This form of surgery appeals to patients and their families due to the fact that it allows only minimal interruption of patient's social life

1. DAY CASE SURGERY
Dr. Alumona

2. OUTLINE
• Introduction
– Definition
– Other forms of ambulatory surgery
– Surgical importance
– History
• Models of care
– Office based care
– Stand alone day surgery facility
– Self contained Integrated Day surgery facility
– Integrated day and short stay surgery facility
• Day Case Work Flow
• Common Day case procedures

3. Outline cont…
• Selection Criteria
– Patient/medical criteria
– Social criteria
– Surgical criteria
• Pre-operative issues, assessment & management
– Pre existing organ function
– Nutritional status
– Physical fitness
– Pre operative fasting
– Patients education and consent
– Pre operative instruction form
• Peri operative management & scheduling
– The theater list
– Pre medication

4. Outline cont…
• Intra operative issues and management
– Anaesthetic technique
– Maintenance of normothermia
– Fluid management
– Minimization of Incision and Mini Invasive Surgery
• Post operative issues
– Pain, PONV etc
– Post op feeding
– Mobilisation
– Drains & catheters
• Discharge
• Follow up
• Challenges in the developing world
• Conclusion

5. INTRODUCTION
• The planned admission and discharge of a patient for a
specific surgical procedure within the 12-hour working day
• Requires full sterile theater and recovery room facility
• A patient pathway extending from first contact to final
discharge
• Success demands that each component of this pathway is
safe, efficient and performed in sequence

6. Intro. Cont…
• Other forms of ambulatory surgery
– Outpatient surgery: not admitted to a ward facility
– Procedure room surgery: surgery not requiring full sterile
theater facility
– Overnight stay/ 23-hour stay: overnight admission with
early morning discharge
– Short stay surgery: admission up to 72 hours
– Inpatient surgery: Requires more prolonged admission.
Patients who are planned as inpatients but discharged
home the same day of surgery counts as Inpatients with
zero length of stay

7. Surgical Importance
• Day case surgery represents high-quality patient care
with excellent patient satisfaction
• Shorter hospital stay and early mobilization reduce
rates of hospital-acquired infections and venous
thromboembolism
• Ensures smaller patient waiting times, less risks of
cancellations, reduces demands on healthcare
resources (human, non human and financial), less
interruption to social life of patients

8. History
– James Nicoll: 20th century Glaswegian surgeon.
9000 paediatric day case procedures. Motivated
by financial benefits, concerns over hospital
acquired infections and lack of bed space
– 1951: first Hospital based day surgery unit opened
in the US, UK (1969)
– 1989: formation of British association of Day case
Surgery (BADS). International Association of
Ambulatory surgery (1995)

9. Models of Care
• Office based care
– Diagnostic and ambulatory interventions are
performed in consultation premises
– Provides readily accessible health care to patients
– Limited to procedure under local anaesthesia +/-
conscious sedation

10. Stand Alone day surgery facility
– A free standing unit not
geographically or
administratively part of any
other health care facility or
– A hospital satellite unit which
is located away from the
parent hospital or within the
campus
– Cases limited to procedures
under LA & RA, minor to
intermediate procedures
under GA

11. Self contained integrated
facility/Hospital autonomous unit
– Structurally part of a hospital
but functionally separate
– Self sufficient: have own
reception, ward, theater, and
recovery areas
– Do not take emergency
admissions
– Have access to parent hospital
facility if required

12. Integrated day and Short stay surgery
facilities
• The hospital OT and recovery rooms are used
for both day cases and inpatients
• More challenging day case procedures can be
carried out

13. Day case surgery Pathway
Pt allowed home to
await surgery
1-3 days before, team
member calls each pt to
access availability
Pt is reviewed by
surgeon and anaesthetic
Fit pt sent to discharge
process
Unfit pt are admitted to
the ward

14. Common Day case procedures (BASKET OF 25)
• 1. ORCHIDOPEXY
• 2. CIRCUMCISION
• 3. INGUINAL HERNIA REPAIR
• 4. EXCISION OF BREAST LUMP
• 5. ANAL FISSURE DILATATION &
SPHICHTEROTOMY
• 6. HAEMORRHOIDECTOMY
• 7. LAPAROSCOPIC CHOLECYSTECTOMY
• 8. VARICOSE VEIN STRIPPING AND LIGATION
• 9. TRANSURETHRAL RESECTION OF BLADDER
TUMOUR
• 10. EXCISION OF DUPUYTRENS
CONTRACTURE
• 11. CARPAL TUNNEL DECOMPRESSION
• 12. GANGLION EXCISION
• 13. HYDROCELE
• 14. SURGERY FOR HALLUX
VALGUS
• 15. REMOVAL OF METALWARE
• 16. EXTRACTION OF CATARACT
• 17. CORRECTION OF SQUINT
• 18. MYRINGOTOMY
• 19. TONSILLECTOMY
• 20. SUBMUCOUS RESECTION
• 21. OPERATION FOR BAT EAR
• 22. REDUCTION OF NASAL
FRACTURE
• 23. D&C HYSTEROSCOPY
• 24. LAPAROSCOPY
• 25. TERMINATION OF
PREGNANCY

15. • TROLLEY of procedures: Recommended by the
British Association Of Day Surgery (BADS)
• Contains 50 procedures such as laparoscopic
fundoplication, laser prostatectomy, arthroscopy of
knee & shoulder, thoracic sympathectomy to be
done on day case basis.

16. Selection Criteria
• Medical criteria
• Social criteria
• Surgical criteria

17. Medical criteria
• Age: no upper age limit
• Comorbidity
– ASA 1&2 for stand alone units, ASA 3 for integrated
facilities
– Diabetes: controlled Types 1&2 with HBA1c < 8.5%
• Should be first on list
• Morning list patients can skip morning dose of oral
hypoglycemic meds or insulin
• Afternoon list patients and patients on continuous sc
infusion are managed closely with diabetic team
– Hypertension: <180/110mmhg

18. – Epilepsy: Well controlled pts continue routine
meds in the pre operative period
• Poorly controlled pts are reviewed with medical team.
• Social support is very important
– Obesity: not an absolute contraindication
• BMI: 40 for surface procedures, 38 for laparoscopies
• Reviewed for co-morbidities
• At risk of sleep apnea post operatively
– Anticoagulants: pts with atrial fibrillation, hx of
PTE, or on a metal heart valve must be reviewed
with a cardiologist if surgery requires
discontinuation of anticoagulation

19. Social criteria
• Consent: Patient/care giver must be willing to
cooperate, able to understand, comply and cope
with post-procedural instructions
• Escort: a responsible and physically able adult
• Transport: A journey time of 1hour or less
– Comfortable transportation
• Comfortable home facilities with appropriate toilet
facilities
• Communication: means of communication with
hospital

20. Surgical Criteria
• Simple surgery up to 2hours.
• Minimal risk of postoperative complications e.g.
haemorrhage or airway compromise.
• Minimal postoperative pain that can be controlled by
simple analgesia.
• No special postoperative nursing required post surgery.
• Procedure must not require prolonged immobilization post
operatively
• Rapid return of normal food and fluid intake possible after
the procedure
• Venous thromboembolic risk assessment for prolonged
procedures

21. Pre-operative assessment, issues & management
• Evaluation and optimization of pt’s fitness for
surgery
• Should be performed early in the pathway
• Past medical history and clinical examination
• Basic health screen: BMI, Blood pressure
• Appropriate investigations: FBC, EUCR, Clotting
profile, and other specific investigations
• Best performed by specialist nursing team
suported by an anaesthetist with interest in DCS

22. Assessment and optimization of
nutritional status
– Poor nutritional status is an independent risk
factor for complications after surgery
– Patients with Moderate and severe under-
nutrition benefit from preoperative nutritional
support preferably via enteral route for at least 7
days preoperatively

23. • Evidence supports that it may be beneficial to
provide a drink containing 100g of carbohydrate on
the evening before surgery and a second drink
containing a further 50g upto 2-3hrs before surgery.
– This measure improves
• preoperative feelings of thirst, hunger, anxiety
• reduces post operative insulin resistance and
• reduces the catabolic stress response to surgery

24. IMPROVEMENT OF PHYSICAL FITNESS
– Patients with poor baseline exercise tolerance and
physical conditioning are at increased risk of
serious perioperative complications.
– The strategy of augmenting physical capacity in
anticipation of an upcoming stressor is termed as
PREHABILITATION.
• Observational data suggests that simply instructing the patient to walk for
30min daily in the preoperative period may be beneficial without the need
for a formal individualized exercise program.

25. PRE-OPERATIVE FASTING
• Current preoperative fasting guidelines
recommend a 2 hour fasting for clear liquids
and a 6 hour fast for solids.
• Tailored to suit scheduled time for surgery

26. PATIENT EDUCATION and Consent
• Patient should be provided information about
– Benefits of day care program
– Goals for daily nutrition intake
– Early postoperative ambulation
– Discharge criteria
– Care at home and warning signs to seek medical care
– Expected hospital stay in the event of common
complications
• A written informed consent is obtained

27. PRE OPERATIVE
INSTRUCTIONS
FORM

29. Peri operative management & scheduling
• The theater list
– Dedicated DCS list
– Mixed inpatient and DCS list
• Pre medication
– Benzodiazepins
– Antiemetics eg ondasetron
– Antacids and H2 antagonists
– Analgesics (NSAIDS preferred over opiods)

30. Intra operative issues and management
• ANAESTHETIC TECHNIQUES
– General anaesthesia
• Propofol is the IV agent of choice for induction
• For maintainance anaesthesia desflurane and
sevoflurane are used as they fecilitate early recovery.
• Short or intermediate acting non depolarizing muscle
relaxants are used. Eg cisatracurium, mivacurium
• Sugamadex is a new compound which has shown to
provide faster reversal of non depolarising muscle
relaxants

31. Anaesthetic techniques
– Regional Anaesthesia techniques
– Spinal, epidural and peripheral nerve block have several
advantages over general anaesthesia like
• Improved pulmonary function,
• decreased cardiovascular demand,
• lower incidence of ileus and
• good quality of analgesia at rest and onambulation.
– For faster recovery, minidose lidocaine (10-30mg),
bupivacaine (3.5-7mg) or ropivacaine (5-10mg) spinal
anaesthetic techniques are combined with potent opoid
analgesic like fentanyl (10-25mcg) or sufentanyl (5-10mcg)

32. Anaesthetic techniques
• TIVA techniques using propofol are popular and offer
advantage of reduced post operative nausea and
vomiting.
• Caudal block is used to reduce pain in paediatric patients
for circumcision, herniorraphy, orchidopexy.
• Intra articular local anaesthetics are useful following
arthroscopy.
• Femoral and sciatic nerve block for knee surgery.
• Nerve blocks using portable infusion pumps which the
patient can continue at home.

33. Anaesthetic techniques
• INCISIONAL LOCAL ANAESTHESIA
– INFILTRATION of local anaesthetic is used for
surgical procedures like hernia repair, anal surgery,
breast procedures.
• Long acting local anaesthetic like bupivacaine
should be injected into the wound

34. Intra operative issues and management
• MAINTENANCE OF NORMOTHERMIA
– Mild hypothermia elicits a stress response during
recovery period.
– Maintenance of intraoperative normothermia
with the use of active and passive warming
devices and
– aggressive post operative management of
shivering and residual hypothermia decreases
incidence of wound infection, myocardial
ischeamia and protein breakdown.

35. Intra operative issues and management
• FLUID MANAGEMENT
– Strategies that avoid both hypovolemia and post
operative overload are important in facilitating
fast track recovery process.
– Intraoperative oesophageal Doppler monitoring
can facilitate goal directed fluid administration by
targeting specific values for the cardiac index.
– Soluset for paediatric patients

36. Intra operative issues and management
• MINIMIZATION OF INCISION AND MIS
– The incision should be as small as possible while
allowing adequate exposure
– Laparoscopic techniques must be used whenever
possible

37. Post operative issues
MAJOR MINOR
Pulmonary embolism Pain
Respiratory failure PONV
MI Drowsiness
Haemorrhage
• Reactionary (usually 4-6hours post op)
• Secondary (after 24hours post op)
Minor bleeds
Unrecognised damage to viscous Infection
Headache

38. POSTOPERATIVE FEEDING
• Commencement of oral feeding is tailored
based on
– the procedure and
– patients tolerance.
• For most abdominal surgeries:
– liquids on the night following the operation with
– light solids given on the morning of post op day 1
– normal diet initiated on post op day 2

39. MOBILISATION
• Emphasis on ‘OUT OF BED DAY 0’ strategy
• POST OPERATIVE bed rest should be discouraged.
• Structured post operative mobilization is an
important component of fast track surgery
protocols.
• Patient should be given written instructions that
include specific goals for each day.
• Adequate pain control also helps in early
mobilisation.
• DRAINS and catheters impede independent
mobilisation.

40. DISCHARGE CRITERIA
• Stable vital signs for at least 1hour
• Return to base line orientation
• Ambulation without dizziness
• Minimal pain and PONV
• Minimal bleeding at the surgical site
• Tolerate oral fluids
• Has passed urine
• Responsible adult to take pt home
• Has received supply of oral analgesia, written and verbal
instructions about post op care, follow up appointment
and emergency contact number

41. POST ANAESTHESIA DISCHARGE SCORING
(A TOTAL PADSS SCORE >/= 9
IS
CONSIDERED FIT FOR
DISCHARGE)

42. POST DISCHARGE FOLLOW UP
• PATIENT SHOULD BE ABLE TO Contact the team member
of the day care surgery team should any problem like
fever, wound redness, discharge arise.
• A follow up telephone call should be made 24 to 36 hrs
after the patient goes home.
• Patient should visit the clinic between post operative day
7 and 10 and then seen again at 1 month after the
operation
• Patients are given specific written instructions about the
recovery course.

43. Challenges of DCS in Developing countires
• Lack of awareness in the patient population,
• Poor communication and transport,
• Poor facilities for proper training of doctors in day
surgery specialty and
• Sidelining the surgical specialties.
• Health Ministries in favour of other programmes
particularly those related to HIV/AIDS, Malaria
and Tuberculosis as well as maternal and child
health.

44. Conclusion
• Day case surgery is now an established
practice with rates still increasing around the
world due to advances in anaesthesia and
surgical techniques
• Efforts should be made to utilize evidence
based care to push the frontlines in
developing countries

45. Refrences
• Daniel J Quemby, Mary E Stocker, Day Surgery
Development and practice: key factors for a successful
pathway, continuing Education in Anaesthesia Critical Care
& Pain, Volume 14, Issue 6, December 2014, Pages 256-261,
https://doi.org/10.1093/bjaceaccp/mkt066
• Normal S. Williams, P. Ronan O’Connell, Andrew W.
McCaskie (2018) Bailey & Love Short Practice of Surgery
27th ed.
• MANOJ VAIDYA, Ambulatory surgery, slideshare
• Mukhtiar Ahmad, Anesthesia for Day Case Surgery,
Slidshare

46. • Thank you