Paediatric Surgery as Day-caseCorrespondence:
48 E-33, Venus, Worli Seaface, Mumbai-400 018. India.
E-mail: adyanthaya@hotmail.com
To cite this article:
Adyanthaya Kishore. Paediatric Surgery as Day-case. Day
Surg J of India. 2007. 3:31-33.
Paper received: January 2007. Accepted: March 2007. Source of support: Nil.
Introduction:
One of the biggest series of its kind was published in 1909, James Nicoll (1) performed over 7000 day care procedures in paediatric age group, over a period of 10 years. He realised that admitting children for certain operations "constitutes a waste of resources of a children’s hospital". The results were comparable with patients admitted overnight, as was the trend, with significant savings to the patient and to the hospital. He further added that "with a mother of average intelligence, assisted by advice from the hospital sister, the child fares better than in the hospital." When we talk about Day-care surgery, we still consider minor procedures. Procedures involving major surgeries as Day-case are true Day-care procedures.
History:
Very early in practice, it was realised that delays in Paediatric surgery was unacceptable to the patients as well as the relatives. Thus, giving rise to the beginning of a new era in modern medicine: Ambulatory surgery.
As the surgical technique evolved and became more refined, surgeries like inguinal hernia, did very well with simple herniotomy, without requiring herrnioplasty, as was the norm. Thus came into existence the ‘Gold standard’ in hernia surgery for children. This fact was recognized in Australia (2), and in Europe (3,4,5), since the late 1800s, however in the United States, surgeons (6,7,8), still persisted in performing the traditional repair followed by seven days stay in the hospital followed by two weeks of bed rest at home! Potts (8), though successful in changing the type of surgery for hernia repair, continued to admit his patients for three days for a herniotomy. He believed that the advantages of outpatient surgery were highlighted to cover the inadequacies of hospital in Scotland. A study in the 1950s revealed that there was a significant rate of hospital related infections in children admitted for elective surgery (9). It was only in the 1960s, the economic advantage of outpatient surgery hastened its acceptance (10). This showed that about 40% of all operations in children could be performed without the need for hospital admission. Cloud, in 1972, presented a large series of wide varieties of case performed under general anaesthesia, with endotracheal intubations; demonstrating the safety of this concept. Outpatient surgery or day care surgery, quickly gained momentum and surgical care of children acquired a new style (11.12,13).
The success seen in paediatric patients, led to changes in adult surgical care, making it possible for patients to stay out of the hospital. Now, it is possible to perform about 70% of all operations paediatric age group in a day care setting (14, 15, 16).
As paediatric surgery developed, there was a better understanding of the disease process and patho-physiology of several surgical conditions in children; more operations were gradually added to the list of possible day care cases.
Types of Surgeries:
Surgeries which have been performed and recommended by experts as Day-case:
Adenoidectomy & Myringotomy
Torticollis correction
Cauterisation of umbilical granulomas
Excision of umbilical sinuses Pilonidal sinus Dental surgery These surgeries do not require specialised
nursing care, nor do they need extensive monitoring or intravenous
administration of drugs. Studies have shown that there is a unit cost saving of
between 19-68 %, depending on the operation performed (17). The economics and
hospital management shows an increase in the efficiency as well. The saving is
not only of money, but also on the number of man-hours, the bed can be utilised
more efficiently for critical and needy patients who require nursing care, thus
making it possible for the nursing staff to work more efficiently in caring of
these patients. Even from the patient’s viewpoint, especially in children,
apart from the fear of staying in an unfamiliar environment and spending a night
at the hospital, with unfamiliar people, compounds the stress, delaying
recovery. "A mother of basic intelligence", as has been mentioned several times,
capable of providing nursing care at home, is all that the surgeon needs. In
India, we still have the luxury of joint families, where, there are several
family members to look after the patient. The key to success of Day-case surgery
is the back-up that you can provide. Availability at least over a telephone,
with assurance of taking care of the patient in case over night stay is
required, involvement of family physician in caring for the patient at night and
as and when required, all amount to tremendous confidence in the family of the
operated child. Case selection is of immense importance, distances of over a couple of hours
drive from the surgery centre, lack of basic amenities, inability to look after
the basic needs and situations leading to complications, should be assessed
while posting a patient for surgery. Babies of less than a year old, have increased likelihood of
developing post-operative apnoea, bradycardia and post-procedure chest
infection. Although there is no consensus to the specific lower age, it is
cautioned that term infants under three month of age, and pre-term infants of
less than 48 weeks, post conceptual age, are considered unsuitable for day care
surgery (18, 19). Medically unfit child, with associated conditions,
complicating the post operative course, is obviously not suitable for day care
surgery. Pre-Procedure: Counselling with clear instructions is mandatory for a smooth
procedure. Apart from detailed explanation of the procedure itself, it is
advisable to procure consent, explaining the possible complications and that
they have adequately understood the risks involved. Paediatric surgery is
usually scheduled early in the morning as first case, so as to minimise the
starvation period. Sedation given orally at home the night before, or early in
the morning, just before the procedure itself, is helpful. Intra-operation: Short general anaesthesia is the most frequently used method for paediatric
cases. It is safe for the childand affords adequate time for most procedures.
Pre-op. anaesthetic assessment should be encouraged. Intra muscular sedation can
be given to the patient in the presence of the child so as to minimise he
anxiety of separation. Local or regional blocks are known for minimizing the depth
of anaesthesia and ensuring quick recovery as well as pain relief following
surgery. But, expertise is required. The child is observed in the recovery area till he is awake, assessed again
by the anaesthetist, patient can be discharged. A detailed prescription along
with contact numbers for any queries and emergencies and a set of instructions
is handed over to the parents at the time of discharge. Need of the hour: Day care are existing in most private nursing homes, some
major hospitals still do not recognized its value. Separate spaces for recovery
following surgery are not always available, they form a part of the operation
theatre complex. Tedious admission and discharge procedures defeat the sole
purpose of convenience of Dy surgery. The provision of day-care beds, or the
availability of economical day-care ‘package rates’, with a simplified
registration protocol, is the need of the hour. Also, at present, some insurance companies that reimburse
patients for medical costs still ask for a mandatory 24 hours hospitalisation,
even when there is no justification for the same on medical grounds. Undermining
the very purpose of ambulatory surgery. Knowing very well that an extra charge
is being paid by the insurance company for the overhead incurred in the
overnight hospital stay. Need of the hour: Day care are existing in most private nursing homes, some
major hospitals still do not recognized its value. Separate spaces for recovery
following surgery are not always available, they form a part of the operation
theatre complex. Tedious admission and discharge procedures defeat the sole
purpose of convenience of Dy surgery. The provision of day-care beds, or the
availability of economical day-care ‘package rates’, with a simplified
registration protocol, is the need of the hour. Also, at present, some insurance companies that reimburse
patients for medical costs still ask for a mandatory 24 hours hospitalisation,
even when there is no justification for the same on medical grounds. Undermining
the very purpose of ambulatory surgery. Knowing very well that an extra charge
is being paid by the insurance company for the overhead incurred in the
overnight hospital stay. Internationally: Currently, in U.K., the normal trend of day surgery involves
admission, investigation or treatment, and discharge of suitable patients within
one working day; they have increased their surgeries to almost 80%. In the USA
the concept of ‘23 hour stay’ day surgery has been developed, where by patients
are discharged following surgery within 24 hours of their admission. This has
allowed them to increase the gamut of cases as well as providing adequate time
for post-procedure observation in many major surgeries. In summary: Approximately 60% of surgeries performed by paediatric surgeons can and
should be conducted in Day Care setting. The future day surgery is likely to
include more intermediate operations, such as, laparoscopic surgeries and
surgeries with minimal access, which may require longer duration of
post-operative stay. Increased day surgery will help reduce the waiting period
and free more inpatient beds. The selection of suitable patients and operation,
proper parent’s education and good communication with general practitioners is
the cornerstone of good day care surgical practice. Therefore, over the years,
we can now conclude, that, in appropriate cases, day care surgery in children is
safe and cost-effective. References: 1) Nicoll JH : The Surgery of infancy. Br. Med J,1909,2:753. 2) Russell RH The etiology and treatment of inguinal hernia
in the young. Lancet,1899, 2:1353. 3) Herzfeld G: Hernia in infancy. Am J Surg.1939,
39:422. 4) Czerny V: Syudien zur radkalbehandlung der hernien.
Wien med Wschr, 1877, 27: 497. 5) Banks WM: Notes on radical cure of hernia- London,
Harrison & Sons, 1884 6) Ladd WE,Gross RE,:Inguinal Hernia. In Abdominal surgery
of Infancy and childhood. Philadelphia, W B Saunders,1941 7) Gross RE Inguinal Hernia. In Surgery of Infancy and
Childhood.Philadelphia,1953. 8) Potts WJ , Riker WL, LewisJE : Treatment of inguinal
hernias in infants andchildren ANN Surg,1959, 132: 566. 9) Izant RJ non operative aspects of paediatric surgery.
Report of 27 Ross pediatric research conference. Columbus, Ohio, 1957 10) American medical Association: Factors responsible for
increasing costs of medical care. Chicago, American Medical Association, 1979 11) Cloud DT ReedWA Ford JL: Surgi-center: A fresh concept in Outpatient
Paediatric Surgery: J Paediatr Surgery, 1972, 7:206. 12) Cloud DT Outpatient paediatric Surgery.: A Surgeons View.
Intl Anaestheol cli 1976, 14:130. 13)Reed RA, Ford JL : Development of an independent
outpatient centre. Int Anaesthesiol Clin 1976,14:130. 14) Cloud DT Major ambulatory surgery of paediatric patient .
In Davis JE.(Ed) Major Ambulatory Surgery, Baltimore Willams & Wilkins
1986 15) Morse TS paediatric iutpatient surgery. J Paeiatr Surg,1972,
7:283. 16) Otherson HB, ClatworthyHW Outpatient herniorraphy for
infants Am j Dis Child ,1968,116:78. 17) Presscott R. J. Cuthbertome J., Fenwick N., et. Al.
Economic aspect of day Care after operations for hernia and varicose veins. J.
Epidemiol Comm. Health., 1978, 32:222. 18) Kurth CD, Spitzer AR, Broemule AM: Post-operative apnoea
in pre-term infants, anaesthesiology, 1987, 66, 483-488. 19) Malone JH, Schwartz MZ, Tyson HRT: Out patient Inguinal Herniorraphy in
pre-term infants-is it safe?, J Pediatr. Surg., 1992, 27, 203-208. ----
Laparoscopy / Procedures