Paper received: February 2007. Accepted: March 2007. Source of support: Nil.

The emerging technologies of the late 20th century were developed to allow the practice of medicine and surgery, with minimal trauma, less expense and better clinical outcome. In the next millennium to come, owing to the efficiency of new gadgetry and techniques, these state-of-the-art equipments would propel our hope for more affordable healthcare. Making it worthwhile, the time, funds and manpower, spent in research efforts to develop new technology for better and more cost-effective patient care.

The obvious trend in the 21st century is towards smaller incisions, allowing minimal access surgery to gain headway, since its first introduction fifteen years ago. It is this relatively new modality that has revolutionized the practice of surgery and redefined the standards of holistic patient care, reducing the surgical trauma, lesser pain, lesser hospital stay, better cosmesis, earlier return to normal activity and work; resulting in perhaps better over-all clinical outcomes. Most of our patients nowadays are aware of these advantages and despite the seemingly apparent initial added expense it may entail them, they are willing to explore the possibility of undergoing more of these "band-aid" procedures instead of the time-tested conventional methods. They prefer to undergo procedures that would prevent them from experiencing unnecessary pain and modalities that would save them numerous manpower hours.

The economic, social, health and personal benefits to patients undergoing major surgery under the minimally invasive approach are not simply obvious but tremendously cost-effective and efficient. Patients would rather shell out an initial extra buck rather than be stingy and end up paying a lot more due to prolonged hospital stay and a much greater use of antibiotics, analgesics, and other medications. Less invasive procedures result in better patient tolerance equating a decrease in over-all medical care post surgery.

Patients today are now more concerned and knowledgeable of the different approaches and how procedures for various ailments and conditions can be performed, reducing the hospital stay and total cost, including social aspect of healthcare system. This sudden rise in active patient participation, in peri-operative decision making, can be attributed to the internet revolution and more liberal education of the general population.

Day surgery centers used to be the battle grounds solely for minor lumps and bumps. However, with the advent of minimally invasive procedures, the decrease in morbidity and over-all post-operative care needs, in major cases, has allowed more than a few of these surgeries to be performed on an out-patient setting. Major operations performed through the laparoscopic approach in day surgery centers has been steadily increasing, from hernia repair to cholecystectomy, and from video-assisted thoracoscopic sympathectomy to thyroid surgery.

With minimal pain and little need for close professional nursing care, after surgery, for minor lumps and bumps or major laparoscopic procedures, patients now prefer to recuperate at the comfort of their own homes; at the same time resulting in a decrease in the total expenditures of hospital stay. Medical Centers worldwide are aware of this new patient preference and trend, therefore, smartly joined the bandwagon. Not exempt to this is the National University Hospital of Singapore whose Department of Surgery has been actively developing and refitting its Day Surgery Center to accommodate the needs of patients today. Major surgeries are mostly done in the major operation theatre, thus requiring hospital admissions for the patient with subsequent increase in bed space, manpower and financial demand for the hospital. Even though, morethan 60% of these major surgeries performed, were cases operated on the same-day admission. In recent years, there has been a steady increase in the number of day surgeries performed, except during the critical period of the Severe Acute Respiratory Syndrome (SARS) epidemic, where a significant decrease in day surgeries were noted. However, this decrease does not only cover ambulatory cases but encompasses the entire spectrum of medical care in the region, including hospital admissions.

In recent years, there has been a steady increase in the number of day surgeries performed, except during the critical period of the Severe Acute Respiratory Syndrome (SARS) epidemic, where a significant decrease in day surgeries were noted. However, this decrease does not only cover ambulatory cases but encompasses the entire spectrum of medical care in the region, including hospital admissions.

The steady growth of foreign patient load was hit hard by the Asian financial crisis that swept across the region in the second half of 1997. However, the recovery in the foreign patient load during the post-crisis period has been encouraging. By 2002, the day surgery volume has surpassed the pre-crisis level, while the inpatient volume has returned close to the pre-crisis level. Indonesians and Malaysians have remained the two largest foreign patient groups in our practice.

For the period 1993-1997, patient load for day surgery grew, on an average, by 24.7% p.a., while that for inpatient grew, on average, by 8.6% p.a. (Fig.1).

The Asian financial crisis in late 1997, however, caused foreign patient load to drop sharply by more than one-third in 1998, with the sharpest decline registered in Indonesian and Malaysian patient load (Table 1).

Post-crisis, the situation has been improving. Day surgery patient load grew at a rate of 18.1% p.a. over 1998-2002. Although this was slower than the 24.7% p.a. registered over 1993-1997, in terms of volume, day surgery patient load has out-grown the pre-crisis 1997 level by 20% in 2002 (Table 2).

Indonesian patients returned in strong numbers for day surgery, but now take up a much reduced 48.5% of patient load (1998-2002), compared to 56.0% in 1993-97 (Table 4). Malaysian patients also returned to take up 22.4% of patient load, compared to pre-crisis average of 24.7%. After 1997, North American and British patients increased significantly in numbers and as a share of patient load. The National Health Care Group of Singapore manages a network of hospitals, national specialty centers, polyclinics and business / service divisions. One of its institutions is the National University Hospital, which provides a Day Surgery Centre for the past few years.

One of the major changes that National University Hospital has adopted in the Day Surgery activities is to embark on performing major procedures like laparoscopic herniorrhaphy (even bilateral), thyroidectomy, parathyroidectomy, thoracoscopic sympathectomy, and soon cholecystectomy, to be discharged on the same day. Initial results were encouraging, with no major complications and complaints from the patient, nor the hospital.