DAY CASE SURGERY

DR EGWUONWU I. K
RESIDENT, SURGERY DEPARTMENT
LASUTH IKEJA

23rd August, 2023 1

OUTLINE

 Introduction
 Definition
 Definition of terms
 History
 Surgical importance
 Models of day care surgery
 Advantages
 Patient
 Hospital
 Disadvantages
 Patient
 Hospital
 Selection criteria
 Controversies

23rd August, 2023 2

OUTLINE

 Procedures
 Pre-operative assessment
 Anaesthetic techniques
 Intraoperative principles
 Post operative principles
 Discharge criteria

23rd August, 2023 3

OUTLINE

 Follow-up
 Loco-regional challenges
 Emerging trend
 Conclusion
 References

23rd August, 2023 4

INTRODUCTION

 Ambulatory surgery

 Patient pathway extending from first contact to final discharge

 Each component of the pathway is expected to be safe, efficient and

sequentially performed for a successful procedure

23rd August, 2023 5

INTRODUCTION

 Increasing number of procedures in all specialties are being done

 It minimizes post operative complications

 Range of advantages to patient, hospital and insurance firms

23rd August, 2023 6

DEFINITION

 Day-care surgery is an office or outpatient operation/procedure, where the

patient is discharged on the same working day.

23rd August, 2023 7

DEFINITION OF TERMS

 Out patient surgery– not admitted to ward

 Procedure room surgery– full sterile theatre not required

 Overnight stay– 23-hour overnight admission with early discharge

 Day or same day surgery-admitted and discharged within 12-hour day

23rd August, 2023 8

DEFINITION OF TERMS

 Short stay surgery– admission up to 72 hour

 Inpatient with zero stay—prolonged hospital admission but discharged home

same day of the surgery.

23rd August, 2023 9

HISTORY

 In early 20th century; James Nicolle a Norwegian surgeon had about 9000
paediatric cases who was motivated by ease of practice and financial gain

 1951: first hospital based day case surgery opened in US and UK

 1989: British Association of Day Case Surgery formed(BADS)

 1995: International Association of Ambulatory Surgery(IAAS)

23rd August, 2023 10

SURGICAL IMPORTANCE

 High-quality patient care with excellent satisfaction and early ambulation

less interruption to social life of patients

23rd August, 2023 11

DAY CASE PATHWAY

23rd August, 2023 12

MODEL OF CARE

 Office based care:

 Limited to procedure under local anaesthesia/ conscious sedation

 Diagnostic and therapeutic interventions are done in consultation room

23rd August, 2023 13

MODEL OF CARE

 Stand alone day surgery

 A hospital which is located away from the parent hospital or within campus

 Cases are limited to procedures under L.A, spinal, minor to intermediate under
G.A

23rd August, 2023 14

MODELS OF CARE

 Self-contained integrated facility/hospital autonomous unit:

 Structurally part of the parent hospital but functionally independent



 Self-sufficient: separate reception, theatre and recovery unit

 Have access to parent hospital facility if required

 Does not take emergency cases

23rd August, 2023 15

MODELS OF CARE

 Integrated day and short stay surgery facilities:

 The theatre is used for both day and inpatient cases, more challenging day cases
can be done there.

23rd August, 2023 16

ADVANTAGES

 PATIENT
 Early return to routine activities

 Reduced case cancellation

 Reduced anxiety on hospital admission

23rd August, 2023 17

ADVANTAGES

 PATIENT:

 Early ambulation

 Cost effective

 Less stress to caregiver

23rd August, 2023 18

ADVANTAGES

 HOSPITAL
 Reduced nosocomial infection

 Efficient scheduling of operation list

 Reduced morbidity

 Reduced demand on inpatient bed space

 Light workload on staff

23rd August, 2023 19
DISADVANTAGES

 PATIENT

 more outpatient visitation

 More responsibility on parents and caregivers

23rd August, 2023 20

DISADVANTAGES

 HOSPITAL:

 Higher rates of treatment failure

 Greater workload on nursing staff

 Reduced revenue generation

 Less exposure of residents and medical students

23rd August, 2023 21

SELECTION CRITERIA

 Surgical

 Medical

 Social

23rd August, 2023 22

SURGICAL CRITERIA

 Duration of surgery less than 1hr

 Minimal risk of complications –bleeding, PONV,

 Pain manageable by simple analgesia

 Simple nursing care

23rd August, 2023 23

MEDICAL CRITERIA

 Age; not more than 75 years

 Psychologically motivated and fit



 BMI<30kg/m2 or <35kg/m2

 ASA 1 and 2 with well controlled disease such as DM with HBA1C<8.5%

 Anticougulants: patients with arterial fibrillation, PTE, or valvular heart disease

should be reviewed by cardiologist for anticoagulation
23rd August, 2023 24
SOCIAL

 Consent; patient/caregiver must be motivated for the procedure



 Availability of means of communication with hospital

 A competent adult is required to accompany the patient home

 Journey time of not more than 1hr

23rd August, 2023 25

CONTROVERSIES

 Age
 full-term infants of more than 1 month age and 60 weeks post-conception age in
premature born for day case procedures,
 Elderly with multiple diseases are offered care
 No significant relation with pre-existing diseases and post-op complications

23rd August, 2023 26

CONTROVERSIES

 Hypertension
 No clear evidence of deferring surgery for Bp </=160/100mmhg

 Obesity
 Patient with BMI of 40kg/m2 are suitable for DCS

 The early ambulation is even considered clinically relevant for them

23rd August, 2023 27

CONTROVERSIES

 Epilepsy
 Continue medications

 Urgent DCS:
 Urgent procedures can be done via semi-elective pathway

 Reduces postponement in main hospital

 Fracture manipulation, tendon repairs, laparoscopic ectopic pregnancy

23rd August, 2023 28

CONTROVERSIES

 Patient on anticoagulant and anti-platelets;

 VTE in last 3 months are unsuitable for day case surgery

 Cardiologist review

23rd August, 2023 29

CONTROVERSIES

 Obstructive sleep apnea

 Diabetes mellitus

 Recommended blood glucose level <8mmol, HBA1C <8.5%

 Local anaesthetic preferred

23rd August, 2023 30

CONTROVERSIES

 Haematological disorder:
 Consultation with haematologist is recommended
 Emphasis on platelets level

 Alcohol:
 Increases risk of opioid- induced respiratory depression.

23rd August, 2023 31

CONTROVERSIES

 Neurological disorder:

 Mysthaena gravis is a contraindication for DCS

 Others required admission for the perioperative period for risk of respiratory
 failure and aspiration and comparison of clinical status in pre- and post operative
periods

23rd August, 2023 32

CONTROVERSIES

 American Aanaesthesiologist Society (ASA)

 Few ASA 3 and 4 are suitable for DCS

 Psychiatry and cognitive disorders are not contraindicated

23rd August, 2023 33

CONTRAINDICATIONS

 Risk of severe haemorrhage

 Cardiovascular instability

 Mysthaena gravis

 Vagrant

 ASA 5

23rd August, 2023 34

PROCEDURES

 General surgery;
 Excision biopsy- lipoma, breast lump,
 Laparascopic cholecystectomy
 Herniorrhaphy
 Lymph node biopsy
  laparoscopic appendicectomy
 incision and drainage

23rd August, 2023 35

PROCEDURES

 Orthopaedics;
 Arthroscopy
 Cruciate ligament repair
 Release of trigger trigger finger
 Carpal tunnel release

23rd August, 2023 36

PROCEDURES

 Urology
 Vasectomy
 urethrocystoscopy
 Hydrocelectomy
 meatoplasty
 Prostate biopsy

23rd August, 2023 37

PROCEDURES

 Reconstructive surgery;
 Breast reduction
 Liposuction
 Zodek procedure
 Soft tissue release
 Excision of Deputyrens contracture

23rd August, 2023 38

PROCEDURES

 Paediatric surgery
 Herniotomy
 Circumscision
 Release of ankyloglosia
 Sistrunk procedure
 EUA
 Meatotomy
 Rectal biopsy

23rd August, 2023 39

PROCEDURES

 Obstetric and gynaecology

 Laparoscopic hysterectomy
 Evacuation of retained products of conception
 Cone biopsy

23rd August, 2023 40

PRE-OPERATIVE ASSESSMENT

 optimization of patient should be done early for the surgery

 History and clinical examination

 Basic screen –BMI, BP

 Appropriate investigations; CBC, EUCR, clotting profile and other specific

investigations

23rd August, 2023 41

PREOPERATIVE ASSESSMENT

 Fasting for at least 6 hours or 2 hours of clear fluid



 Preoperative review by a specialist nurse and or anaesthetist

23rd August, 2023 42

ANAESTHETIC TECHNIQUE

 General anaesthesia

 TIVA

 Caudal

 Intra-articular local block

 Nerve block

23rd August, 2023 43

INTRAOPERATIVE

 Maintain normotthermia

 Avoid hypovolemia and fluid overload to fast track recovery process

 Soluset used in paediatric patients

 Minimal incision while allowing adequate exposure

23rd August, 2023 44

POST OPERATIVE COMPLICATIONS

MAJOR MINOR
Haemorrhage PONV
Surgical site infection pain
Pulmonary embolism Drowsiness
Damage to contiguous structure Headache
Unrecognized damage to viscus Anxiety
Pulmonary embolism
Re-admission

23rd August, 2023 45

DISCHARGE CRITERIA

 Stable vital signs for at least 1hr

 Orientation to place, person and time

 Ambulation without dizziness

 Minimal pain and PONV

 Tolerate oral food

23rd August, 2023 46

DISCHARGE CRITERIA

 Return to baseline orientation

 Urination

 Responsible adult to take patient home

 Has received oral analgesia, written and verbal instructions on post care,
follow up and emergency contact number

23rd August, 2023 47

POST OPERATIVE DISCHARGE SCORE

23rd August, 2023 48

FOLLOW UP

 A follow-up telephone call should be made 24 to 36hours after patient has

gone home

 Clinic visitation between 7th to 10th day and again 4th week post op

 Recovery course is written for the patient

23rd August, 2023 49

LOCO-REGIONAL CHALLENGES

 sidelining of surgical specialties

 Poor communication and transport

 Lack of awareness

23rd August, 2023 50

EMERGING TREND

 One-stop clinic:
 Short interval between decision to treat and surgery

 Access to consultation, investigation, optimization

 Provides pool of patient should cancellation arise

 Manpower and financial demands are stretched

23rd August, 2023 51

CONCLUSION

 Day case surgery is now an established practice with rates still growing world
wide due to advances in anaesthesia and surgical technique
 Efforts should be made to utilize evidence based care to promote its practice
especially in developing nations

23rd August, 2023 52

REFERENCES

 http://www.bads.co.uk
 https://www.ncbi.nlm.nih.gov
 Kasieme et al, viva in surgical principles and operative surgery, afrobrilance
academics, 2009 first edition, pp.96-97
 Oxford Handbook of Clinical Surgery, 4th edition
 Montgomery j et al. Ten dilemmas in pre-operative assessment for day
surgery: BADS handbook. Norwich, UK: Coleman print; 2009. pp. 1–34. 
 Bailey and Love short practice of surgery. 26 edition

23rd August, 2023 53

THANK YOU

23rd August, 2023 54