Discussion:
World over, more and more cases are being performed as Day Case.
With the continued development of scientific knowledge and modern technology, the discipline of surgery expanded into many specialities and single-subject sub-speciality, to the betterment of patient care. (4)
Although many general surgeons consider themselves to be hepatobiliary, pancreatic, laparoscopic or some-specialist, the truth is that virtually most of us perform our share of ‘bread and butter, everyday procedures.
A general surgeon’s regular OT list does not contain Hepatectomy, Colectomy, Parathyroidectomy and Pancreatectomy as part of the list of common surgical procedures. They are rare! Circumcision, incision and drainage of paronychia and scar revision are very common, and in fact perhaps more numerous than those listed above. (5)
Countries pioneering this concept, are utilizing Day Surgery for the benefit of millions of patients. In the United States, Ambulatory procedures have risen from 27.7 million cases in 1994 to more than 40 million cases this year. (6)
In our country too, in a study conducted in a government hospital, up to 50% of reduction in the cost of surgical care has been shown by the use of Day Care Surgery.(7)
Minor surgical procedure forms the bulk of all the cases, undergoing procedure at our centre, that is 1777 cases; though these are considered to be OPD cases, are included in the Day Care Surgery list as the precautions have to be taken same as that of Major cases and some of them do need a good amount of sedation, hence, 3 to 4 hours of post-operative recovery period.
Day Care surgery as a speciality is still in its infancy in India. Though, this concept is widely used, cases are mostly done as part of routine list, where the patients are hospitalised and have to undergo the same formality as for indoor patients.
Now, there are some large hospitals in metropolitan cities, which have incorporated a separate Day surgery unit along with the causality, but these are few in numbers.
Free standing centres, that is, Day Care Surgery Centres, run by individual specialists, are smaller in size as per the number of beds, to cater to a population of over a billion people. Also, they are very few in number; most of them are confined to the bigger cities.
There is a need for several dedicated day care centre with a fully equipped operation theatre consisting of Anaesthetic apparatus, Pulse Oximeter, Cardioscope, Electrocautry, Defibrillator, etc. Recovery area or rooms, where post operative care is given by trained staff, helping in patient’s recuperation and handling of complications, is mandatory. Training of Medical and Nursing staff, dedicated and well versed in the management of Day Care surgery patients, is a must for the efficient functioning of the centre.
"Convenience" is the key word to be kept in mind while setting up a Day Care Surgery centre. In the metropolitan cities, restriction of space makes you innovative. Here one tries to provide every necessary detail required in the minimum of space, without compromising on the quality. (8)
The first modern day unit was established in 1969, in Phoenix, Arizona, USA. The ‘Surgicenter’ was the prototype of a ‘free standing’ unit, on which are based all centres all over the USA. (9)
Advantages of Day Surgery are many, they are time tested and proven, over a period of time, in our practice, the once which we found to be of significance are briefly illustrated:
A day procedure, which does not entail overnight admission, makes it look like a ‘Minor’ surgery to the patient, therefore, reduces the anxiety of surgery, which always makes its presence felt when ever a patient hears the word ‘Surgery’. Being a Day procedure, it reduces the hospital stay, thus reducing the chance of hospital acquired infection. Since most of the surgeries are done under regional or local anaesthesia, the side effects of general anaesthesia is considerably reduced, making it an ideal method of surgery in cases where general or spinal anaesthesia is to be avoided. Most of the patients have conscious sedation; their requirement for post-operative starvation is less. The recovery is faster and in familiar surroundings, which is very important for the recovery of patients of older age group and children. An early resumption of day to day activity along with the other benefit makes it cost effective, in the long run.
In a busy hospital set up with limited beds, Day procedures help in making indoor beds free, for the admission of other patients who need to be hospitalised. Similarly, a separate Day Surgery theatre will reduce the wait list and overload of any regular theatre complex.
Disadvantages of Day Surgery practice, on the other hand, certain points to be kept in mind, which can be considered as: The patient is given instructions with regards to pre-operative preparation, such as, bowel preparation, overnight fasting, anti-hypertension medication, etc., which either they fail to take or take incompletely, resulting in poor bowel preparation or delay in surgery. This is avoided if instructions are written down and repeated verbally to the patient and attendant.
Operative position like Jack-knife, Lithotomy or Supine position, may be found to be uncomfortable as most of the day procedures are performed under Local anaesthesia or Conscious sedation.
Failure of local blocks, due to technical reasons, can lead to substitution of deeper form of anaesthesia, leading in the delay of patient’s recovery.
Since the concept of Day surgery is not well known, the idea of being discharged on the same day of surgery, does not go down too well with most of the apprehensive patients, therefore, some of them may refuse to being discharged on the same day.
Lack of facilities at home, in the form of absence of a responsible person to take care of the patient, remote areas which do not have accesses to medical facilities in case of any complication, would also not be fit for day procedure of the major type, and hence is considered as a disadvantage.
Patient selection criteria: which we used for the Day surgery at our centre, helped us in proper safeguard of the patients, to discuss them:
We chose medically fit / stable patients; falling within the recommendation of American Society of Anaesthesia I, II, and III (well controlled).
Our patients were well motivated for Day Surgery and psychologically / mentally stable.
Emphasis on the presence of responsible relation at home to take care of the patient, if needed, contact our team or bring the patient to us in case of any complications, was made.
We recommended for the convenience of the patient’s post operative recovery, the facilities of toilet, transport and telephone, at or near the residence of the patient, so as to be able to recoup comfortably.
Absolute contraindication for Day Surgery, when we discussed, we kept in mind that:
Medically unfit; those patients who do not qualify within any of the ASA category.
Patients suffering from highly infectious diseases, which need isolation, are not ideal for recovery at home, if they are to be operated, then, they should be hospitalized.
Patients suffering from severe upper respiratory tract infection, which can lead to bronchospasm, needing medical support, are best treated as indoor cases.
Premature babies are prone to respiratory tract infection and dehydration.
Patients who are in shock due to the disease or trauma and requiring extensive post-operative monitoring, are not ideal candidate for Day Case procedures.
Even high fever, for any reason, needing to undergo surgery would require to be hospitalized for observation.
Lastly, patients having mental retardation, as they are in no position to look after them, hence needs supervision, should not be operated as day case.
Relative contraindications are subject to case selection and surgeon’s discretion. Depending on type of surgical or invasive procedure, these patients undergoing Day Surgery, are:
Obesity, as their requirement of anaesthesia will be more and surgery will be technically difficult due to the presence of excessive sub-cutaneous fatty tissue.
Babies younger that 6 months of age are at risk of upper respiratory tract infection and dehydration is high in these cases.
Long distance from home, if patient have to travel long distances to their residences after the procedure, there is a possibility of increasing their morbidity due to the travel.
Procedure: the most important aspect of a Day Surgical procedure is the anaesthesia part. In our practice, the combination of 2% Lignocaine HCL and 0.5% Bupivacaine, have found to give the advantage of immediate and prolonged anaesthesia at the site of surgery. Lignocaine acts almost immediately, but wears off in 20-30 minutes, Bupivacaine, requires 20 minutes to show its effects, but lasts for almost 8 hours. Toxicity of the local anaesthesia is also avoided as the combination gives a diluted strength of 1 %.
One should keep in mind, the toxic dose of Lignocaine HCl with adrenaline is 7 mg/kg, plain lignocaine has a maximum dosage of 3 mg/kg, where as bupivacaine is 2 mg/kg body weight. For example, the usual amount of local anaesthesia required for one sided inguinal hernioplasty is about 30 ml of the combination, which is well within the toxicity dose. Though sensitivity to local anaesthesia used is very rare, as the most commonly used agents are Lignocaine and Bupivacaine, which are amides and less toxic than the ester derivatives (e.g. procaine, prilocaine).(10)
Conscious sedation is achieved by a combination of IV drugs, depending on the apprehension and the duration of the cases. At the time of initiating the local block, the patient is sedated with the help of Midazolam (1-2mg), along with Pentazocine (15-30mg) to give analgesia, deeper form of sedation if required is achieved by Ketamine ranging from 10-100mg, bolus dose, as a single drug or in combination. (25mg of ketamine in bolus form, in an adult patient, gives conscious anaelgesia, where as, 100mg is considered to be anaesthetic dose in an adult of 70 kg body weight).
The pain caused by the injection of local anaesthesia is taken care off by this sedation, making the patient virtually painless.
Though the patient is asleep, he can be aroused easily and a repair of hernia can be tested on table.
In cases of appendicectomy, combination of oxygen-nitrous-oxide-halothane was used, in open cases, where spontaneous breathing has been maintained. In patients of Laparoscopic appendicectomy, controlled breathing was achieved by intubation. Muscle relaxant was used in 2 cases only.
The use of IV sedation and anaesthetic drugs make it mandatory to observe the patient for at least 6 to 8 hours, therefore, these cases are preferably conducted in the morning as a first case so as to have enough time for post-operation observation.
Complication: Reaction to local anaesthesia, though rare, is a possibility one should keep in mind. Most commonly seen complications are giddiness, syncope, bradycardia, Nausea, Vomiting; Retention of urine is seen sometimes in male patients; severe pain at home, bleeding, haemorrhage and haematoma, during and after surgery, needing attention.
A home visit by one of our team doctors or a phone call is mandatory for every patient before the centre is closed for the night. However, the involvement of the referring physician of family physician is ideal for the post-operative care of the patient, till they come back to you for follow-up.
The reason for the trend towards increasing outpatient and office procedures are clear: lower cost, greater efficiency and improved patient convenience.
Accomplishing the procedures described in this issue safely, swiftly and successfully will serve legions of patients (and surgeons) well. (11)
Insurance companies, disbursing claims for surgeries performed as Day Case, still demand over 24 hours admission, which is a policy decision to be taken by all the insurance companies together. But, it is just a matter of time.
The Indian Association of Day Surgery, will provide technical data and relevant material for the advancement of Day Surgery in India and hopes to place the recommended practice parameters in place for every Surgeon as a safeguard.
Conclusion:
The results of the analysis of Day Case procedures at our centre were found to be: overall complication: 0.23%; Complication in the Major post operative group was: 0.87%. This is very small, considering the nature of complications.
With proper cases selection and meticulous patient preparation, following the criteria’s for discharge to its last word, will form the guidelines and practice parameters, recommended by us, for the use of cases / procedures which were performed, and listed in the tables, by us, we hope to make Day Care Surgery a worthy modality for the future to come.
The Historic standard: "Is this patient suitable for Day Surgery?" should be replaced by: "Is there any justification for admitting this case as an inpatient?"(12)
Reference:
1) Row T. Naresh, Begani M.M., Day Care Surgery: A General Surgeons Prespective; Bombay Hospital Journal, Special Issue on Day Care Medicine and Surgery, April 2003, Vol.45, No.2, 206-210.
2) Jain Paras, Somani S., Anaesthesia in Day Care Surgery; Bombay Hospital Journal, Special Issue on Day Care Medicine and Surgery, April 2003, Vol.45, No.2, 198-204.
3) Row T. Naresh, Begani M.M., Day Care Surgery in India; The Journal of One Day Surgery, Publication of The British Association of Day Surgery, Spring 2003, Vol. 12, No. 4, 53-54.
4) Gerald J. Bechamps: Editorial, Operative Techniques in General Surgery: Minor Office and Outpatient Procedures: Sept. 2002, Vol. 4, No. 3.
5) van Heerden Jon A., Farley David R., Preface, Operative Techniques in General Surgery: Minor Office and Outpatient Procedures: Sept. 2002, Vol. 4, No. 3.
6) Stats and Facts: Growth of Ambulatory Surgery centers continues, Managed Care Interface, January 2001, 14:32-33.
7) Bapat R.D., et al, Day Care Surgery in A Public Set Up, Bombay Hospital Journal, April 2001, Vol. 43, No. 2, 249-252.
8) Row T. Naresh, Begani M.M., Nariani M.G., Agarwal N.; Setting up a Day Care Centre, Bombay Hospital Journal, Special Issue on Day Care Medicine and Surgery, April 2003, Vol.45, No.2, 280-283.
9) Ford F, Reed W: The Surgicenter-innovation in the delivery and cost of medical care. Ariz Med, 1969, 26:801.
10) Tuckley J.M.: The Pharmacology of Local Anaesthetic agents, Update in Anaesthesia, 1994; Issue 4, 1-3.
11) van Heerden Jon A., Farley David R., Preface, Operative Techniques in General Surgery: Minor Office and Outpatient Procedures: Sept. 2002, Vol. 4, No. 3.
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