Letters to Editor
Potential of Day-care Surgery for a General Surgeon.
Dear Editor,
I am interested in sharing my work & my evolution to day care in the presented to you and our readers, through this letter. I do hope this will be an inspiration to others and highlight the difficulties I faced in my practice.
In 1981, after master’s degree from Mumbai University, I started my practice in Kandivali with concept of One-Day Surgery in a 2000 sq. feet area. My first sign board "Vrindavan Ambulatory Surgical Center" had to be changed to "Vrindavan Nursing Home" as the name was not acceptable by any doctor at that time.
In 1984, I could gather enough courage to again put up a new board "Ambulatory Surgical Center" after giving up Urology; later, all other surgeries except Hernia, Piles, Fissure, Hydrocele & occasional planned Appendix surgeries on non-emergency but, one day basis. Now our name is "Vrindavan Hernia Institute & Piles Center" since the past 20 years.
Our staff consists of me as Chief surgeon. One full time Anaesthetist and one on call; 2 Doctors, 3 OT Assistants, 7 sisters, 1 ward boy, 2 Ayas, 1 Receptionist and 1 Accountant.
We perform approximately 3 to 4 surgeries per day, with an OPD Attendance of 25–30 patients per day, including follow-ups. We have 2 dedicated theatres, one for clean cases and the other for Septic cases. We work from 2 pm to 8 pm (for surgeries as well as consultations).
We have operated over 10,000 Hernia Surgeries (4,000 in first 15 years, 6,000 in second 11 years) and 6,500 Anorectal Surgeries (4,000 in first 15 years and 2,500 in next 11 years).
I am very much involved and interested in Hernia Surgeries. I achieved a less than 1% Recurrence Rate, with Shouldice’s repair, in the first 15 years. Then, I switched over to ‘Plug method’ for Indirect Inguinal Hernia and ‘Patch Method’ in sliding and Direct Hernias, with less than 0.5% Recurrence Rate, all operated under Local anaesthesia. Almost all Inguinal, Umblical, Epigastric, Spigelian & small Incisional, at our centre are performed under Local anaesthesia, with an Anaesthetist as stand-by and the patients walk to their room after the surgery.
We have almost zero infection rates and daily fumigation our OT. Surgeons from all over India have come to our centre for a better understanding of Hernia Surgery since over 20 years.
For Anal surgeries: Piles with Fissure-in-ano, depending on the degree of pathology, we use Sclerotherapy with lateral Sphincterotomy or closed Haemorrhoidectomy with lateral Sphincterotomy; in Jack Knife position, under local Anaesthesia with short acting sedation, to avoid pain of local injections. Patients walk back to their rooms from the Operation Theater.
On an average, patients are discharged after 5 hours stay in the hospital, after they have fulfilled the discharge criteria’s.
Our staff nurse calls up each patient pre & post operatively (till needed). Patient is informed about all possible complications of each surgery, like wound infection, with instruction to inform us immediately, on the first indication of any change. Our follow-up calls also inquire about all symptoms in detail.
Over 25 years as a Day-care Hernia & Piles Surgeon, I have no regrets. I do hope, the younger generation of surgeons, will be able to use our experience as an inspiration and further the cause of Day Care surgery.
Ambulatory surgery is now more accepted, but, awareness has to be increased, I do hope that our Association will make good progress and make it easy for the generation of surgeons and patients to come. I hope they do not have to face the hardships that I have faced in setting-up my practice.
Regards,
Mumbai.
Intricacies of a mesh.
Dear Editor,
The history of surgical mesh is an important example of the deep cooperation between surgeons and manufacturers, resulting in the continuous progress of the use of biomaterials and its benefits in the hernia surgery.
In literature, Prof. Amid has made the classification of biomaterials and numerous clinical reports and studies have demonstrated the successful application of different kind of mesh in the hernia surgery. Prosthetic mesh is a mix between his design, kind of weave, thickness, pore size, tensile and bursting strength, lightness and stability.
The manufacturers use the same polymers to create a different variety of prosthesis. The non absorbable meshes are extruded monofilament polypropylene. The mesh is manufactured by creating knitted fabric with warp and weave and this webbing is designed to offers the maximum mechanical integrity and stability.
The mesh must have the right strength in both directions. This property is typical of the knitted fabric, and help to determine the right orientation of the mesh during the implantation. According to professor Chu (1985) the direction of the mesh should be parallel to the maximum physiological stress. Other important characteristics to take in consideration are the lightweight and large porous, as described in excellent way in various articles of professor Schumpelick & Klosterhalfen.
Our R&D Department , with the high cooperation of Chemicals, Polymerists ,Texile Engineers and Bioengineers, and following the important teaching of world wide opinion leaders and international literature, has developed Evolution , a new concept of mesh.
The concept is based on the lightweight mesh, large porous but with high stability.
Sometime the concept of lightweight & soft mesh it is legacy to the concept of not much stability and insufficient handling. We’ve gone to research the right balance between the weight and the stability. The results are a light weight mesh with high stability, and this stability favours the good handling and the right positioning during implantation.
As Professor Goldstain said: Select the right mesh is difficult, but understanding some mechanic characteristics, like thickness or rigidity, can help to know the advantages or disadvantages.
Cristina Buemi
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