Discuss Day Case

Surgery
Dr Nwosu C
Dept of Surgery
JUTH
 Outline
 Introduction
 Design of Day Case Surgery
 Advantages & Disadvantages
 Patient selection
 Operation selection/Day case procedures
 Contraindications
 Pre-op preparation
 Anaesthesia & Post Anaesthesia Recovery
 Post op care
 Discharge criteria/ Follow up
 Complications
 Day case surgery in the tropics
 Day surgery in Children
 Future trends/ conclusion
 Introduction
 Definition
 History

James Nicoll –Scottish surgeon(1909)

Ralph Waters –USA (1912)
Eric Farquharson –(1951)
1960 –Hospital based DSU’s
1969 –Walter Reed American Surgeon
1970s -DSU’s in UK hospitals
 Design of Day Case Surgery
 3 main forms
1. Day Surgery Unit
2. Day Case Ward
3. General ward
 1.Day Surgery Unit
 Self contained dedicated DS facility
 Highly organized and efficient
 Same high standards
 Adjacent parking space
 Trained, experienced staff
 1.Day Surgery Unit
 Teamwork, liaison with community services
 Management, audit and Quality control
 The reception area
 Day surgery ward
 Anaesthetic room & operating theatres
 Recovery area
2.Day case ward
3.General ward
 Advantages
1. Patients
-minimal time away from home
-↓sed disruption of normal activities
-↓ced waiting period
-lower complication rate
-cost effective
2. Surgeons
-better scheduling of cases
-↑sed turnover of cases
-↓ced delay between cases
-greater fulfillment
 Advantages
3. Hospital management
-greater efficiency
-in patient bed available
-closed at nights and weekends
 Disadvantages
 Increased burden for relatives
 Reduced training opportunity
 Initial setting up cost
 Patient selection
1. Physical fitness
-Age < 70yrs
-ASA I or II
-Generally fit and ambulant
-BMI <30
2. Social factors
-responsible adult
-live within an hour’s drive
-conducive home circumstances
3. Associated medical conditions/ drug history
 Operation selection/ Day Case
procedure
 Criteria
-minor cases
-low risk of post-op complications
-duration
-pain control
-reasonably ambulant afterwards
-not require blood, IVF or IV drugs
-drains, catheter, skin closure
 Day Case Procedures
 Diagnostic
A. General Surgery
-endoscopy
-tissue biopsies
-radiographic
-laparoscopic
B. Urology
-endoscopy
-tissue biopsies
C. Orthopaedic
-biopsies -open or arthroscopic
D. Plastic surgery
-biopsy of skin lesions
 Day case procedures
 Therapeutic
A. General surgery
-endoscopic
-open procedures
-radiological
-laparascopic
B. Urology
-intravesical instillations
-urethral stricture
-endoscopy
-open procedures
 Day case procedures
-laparascopic
C. Orthopaedics
-arthroscopy
-removal of implants
-MUA
D. Plastic surgery
-excision of skin lesions
-revision of flaps/ scars
-insertion and distention of tissue expanders
-cosmetic surgeries
 Contraindications
 Medical
 Psychological
 Social
 Pre op preparation
 Seen at pre admission clinic
1. Explain nature of problem and intended surgery
2. Protocol of the day unit
3. Fasting; accompanying person
4. Transport ; informed consent
5. Relevant investigations
6. Post op restrictions
7. Staggered arrival
8. Check site and investigations
 Anaesthesia and post anaesthetic
recovery
 Principles of anaesthesia same
 Problem free recovery
 Experienced anaesthetist
 LA encouraged
 High quality induction, notice of recovery for GA
 LA
 GA
 3 stages of recovery from GA
 Recovery room
 Ward
 Post op Management
 Fundamentally different
 Meticulously planned
 Duration
 Usual problems of management
 Post op visit before discharge
 Discharge Criteria
 Criteria
a) No complications
b) Stage 2 recovery
c) Tolerate fluids and pass urine
d) Understand post op restrictions
e) Responsible adult
f) Discharge summaries
g) Contact
 Follow up
 Post op instructions
A. Drive or operate machinery
B. Important decisions/ signing documents
C. SOPD
 Complications
 Incidence of major complications -0.0007%
 Minor complications
Early
a. Pain
b. N&V
c. Dizziness and drowsiness
d. Minor bleeding
Late
1. Delayed discharge <2-3%
2. Readmission 4%
3. Sepsis
4. Sore throat, headache
 Day case surgery in the Tropics
 Early stages
 General ward setting
 Poorly organised
 Poor follow up and cannot be assessed
 Severe constraints
 Lack of political will/ vision
 Cancellations and reasons
 Day surgery in JUTH
 Day surgery for children
 50% of surgical procedures in children
 Ideal for children with psychological benefits
 Careful planning with trained staff
 Children’s DSU or children only days
 Pre admission visits
 Children friendly surroundings
 Duration of anaesthesia
 Separate rooms with special facilities
 Future trends
 Scope expected to expand
 More invasive procedures on less fit patients
Conclusion
 References
 Al Fallouji M A R- Post graduate surgery
 Badoe et al –Principles and practice of surgery
 Russel R C G et al- Short practice of Surgery
 www.surgical-tutor.org.uk
 www.gpnotebook.co.uk
 Dakum et al –Cancellations of Urological day
care surgeries