Discuss Day Case Discuss Day Case SurgerySurgeryDr Nwosu CDr Nwosu C

Dept of SurgeryDept of SurgeryJUTHJUTH

OutlineOutline IntroductionIntroduction Design of Day Case SurgeryDesign of Day Case Surgery Advantages & DisadvantagesAdvantages & Disadvantages Patient selectionPatient selection Operation selection/Day case proceduresOperation selection/Day case procedures ContraindicationsContraindications Pre-op preparationPre-op preparation Anaesthesia & Post Anaesthesia RecoveryAnaesthesia & Post Anaesthesia Recovery Post op carePost op care Discharge criteria/ Follow upDischarge criteria/ Follow up ComplicationsComplications Day case surgery in the tropicsDay case surgery in the tropics Day surgery in ChildrenDay surgery in Children Future trends/ conclusionFuture trends/ conclusion

Introduction Introduction DefinitionDefinition History History James Nicoll –Scottish surgeon(1909)James Nicoll –Scottish surgeon(1909) Ralph Waters –USA (1912)Ralph Waters –USA (1912) Eric Farquharson –(1951)Eric Farquharson –(1951) 1960 –Hospital based DSU’s1960 –Hospital based DSU’s 1969 –Walter Reed American Surgeon1969 –Walter Reed American Surgeon 1970s -DSU’s in UK hospitals 1970s -DSU’s in UK hospitals

Design of Day Case SurgeryDesign of Day Case Surgery 3 main forms3 main forms1.1. Day Surgery UnitDay Surgery Unit2.2. Day Case WardDay Case Ward3.3. General wardGeneral ward

1.Day Surgery Unit1.Day Surgery Unit Self contained dedicated DS facilitySelf contained dedicated DS facility Highly organized and efficientHighly organized and efficient Same high standardsSame high standards Adjacent parking spaceAdjacent parking space Trained, experienced staffTrained, experienced staff

1.Day Surgery Unit1.Day Surgery Unit Teamwork, liaison with community servicesTeamwork, liaison with community services Management, audit and Quality controlManagement, audit and Quality control The reception areaThe reception area Day surgery wardDay surgery ward Anaesthetic room & operating theatresAnaesthetic room & operating theatres Recovery areaRecovery area

2.Day case ward2.Day case ward

3.General ward3.General ward

Advantages Advantages 1.1. Patients Patients -minimal time away from home-minimal time away from home --↓sed disruption of normal activities↓sed disruption of normal activities -↓ced waiting period-↓ced waiting period -lower complication rate-lower complication rate -cost effective-cost effective2.2. Surgeons Surgeons -better scheduling of cases-better scheduling of cases -↑sed turnover of cases-↑sed turnover of cases -↓ced delay between cases-↓ced delay between cases -greater fulfillment -greater fulfillment

Advantages Advantages

3.3. Hospital managementHospital management -greater efficiency-greater efficiency -in patient bed available-in patient bed available -closed at nights and weekends-closed at nights and weekends

Disadvantages Disadvantages Increased burden for relativesIncreased burden for relatives Reduced training opportunityReduced training opportunity Initial setting up costInitial setting up cost

Patient selectionPatient selection1.1. Physical fitnessPhysical fitness -Age < 70yrs-Age < 70yrs -ASA I or II-ASA I or II -Generally fit and ambulant-Generally fit and ambulant -BMI <30-BMI <302.2. Social factorsSocial factors -responsible adult-responsible adult -live within an hour’s drive -live within an hour’s drive -conducive home circumstances-conducive home circumstances3.3. Associated medical conditions/ drug historyAssociated medical conditions/ drug history

Operation selection/ Day Case Operation selection/ Day Case procedureprocedure

Criteria Criteria -minor cases-minor cases -low risk of post-op complications-low risk of post-op complications -duration-duration -pain control-pain control -reasonably ambulant afterwards-reasonably ambulant afterwards -not require blood, IVF or IV drugs-not require blood, IVF or IV drugs -drains, catheter, skin closure-drains, catheter, skin closure

Day Case ProceduresDay Case Procedures DiagnosticDiagnosticA.A. General SurgeryGeneral Surgery -endoscopy-endoscopy -tissue biopsies-tissue biopsies -radiographic-radiographic -laparoscopic-laparoscopicB.B. UrologyUrology -endoscopy-endoscopy -tissue biopsies-tissue biopsiesC.C. OrthopaedicOrthopaedic -biopsies -open or arthroscopic-biopsies -open or arthroscopicD.D. Plastic surgeryPlastic surgery -biopsy of skin lesions -biopsy of skin lesions

Day case proceduresDay case procedures Therapeutic Therapeutic A.A. General surgeryGeneral surgery -endoscopic-endoscopic -open procedures-open procedures -radiological-radiological -laparascopic-laparascopicB.B. UrologyUrology -intravesical instillations-intravesical instillations -urethral stricture-urethral stricture -endoscopy-endoscopy -open procedures-open procedures

Day case proceduresDay case procedures -laparascopic-laparascopicC.C. OrthopaedicsOrthopaedics -arthroscopy-arthroscopy -removal of implants-removal of implants -MUA-MUAD.D. Plastic surgeryPlastic surgery -excision of skin lesions-excision of skin lesions -revision of flaps/ scars-revision of flaps/ scars -insertion and distention of tissue expanders-insertion and distention of tissue expanders -cosmetic surgeries-cosmetic surgeries

Contraindications Contraindications MedicalMedical PsychologicalPsychological Social Social

Pre op preparationPre op preparation Seen at pre admission clinicSeen at pre admission clinic1.1. Explain nature of problem and intended surgery Explain nature of problem and intended surgery 2.2. Protocol of the day unitProtocol of the day unit3.3. Fasting; accompanying personFasting; accompanying person4.4. Transport ; informed consentTransport ; informed consent5.5. Relevant investigationsRelevant investigations6.6. Post op restrictionsPost op restrictions7.7. Staggered arrivalStaggered arrival8.8. Check site and investigationsCheck site and investigations

Anaesthesia and post anaesthetic Anaesthesia and post anaesthetic recoveryrecovery

Principles of anaesthesia samePrinciples of anaesthesia same Problem free recoveryProblem free recovery Experienced anaesthetistExperienced anaesthetist LA encouragedLA encouraged High quality induction, notice of recovery for GAHigh quality induction, notice of recovery for GA LALA GAGA 3 stages of recovery from GA3 stages of recovery from GA Recovery roomRecovery room Ward Ward

Post op Management Post op Management Fundamentally differentFundamentally different Meticulously plannedMeticulously planned DurationDuration Usual problems of managementUsual problems of management Post op visit before dischargePost op visit before discharge

Discharge CriteriaDischarge Criteria Criteria Criteria a)a) No complicationsNo complicationsb)b) Stage 2 recoveryStage 2 recoveryc)c) Tolerate fluids and pass urineTolerate fluids and pass urined)d) Understand post op restrictionsUnderstand post op restrictionse)e) Responsible adultResponsible adultf)f) Discharge summariesDischarge summariesg)g) Contact Contact

Follow upFollow up Post op instructionsPost op instructionsA.A. Drive or operate machineryDrive or operate machineryB.B. Important decisions/ signing documentsImportant decisions/ signing documentsC.C. SOPDSOPD

Complications Complications Incidence of major complications -0.0007%Incidence of major complications -0.0007% Minor complicationsMinor complications Early Early a.a. PainPainb.b. N&VN&Vc.c. Dizziness and drowsinessDizziness and drowsinessd.d. Minor bleedingMinor bleeding LateLate1.1. Delayed discharge <2-3%Delayed discharge <2-3%2.2. Readmission 4%Readmission 4%3.3. SepsisSepsis4.4. Sore throat, headache Sore throat, headache

Day case surgery in the TropicsDay case surgery in the Tropics Early stagesEarly stages General ward settingGeneral ward setting Poorly organised Poorly organised Poor follow up and cannot be assessedPoor follow up and cannot be assessed Severe constraintsSevere constraints Lack of political will/ visionLack of political will/ vision Cancellations and reasonsCancellations and reasons Day surgery in JUTHDay surgery in JUTH

Day surgery for childrenDay surgery for children 50% of surgical procedures in children50% of surgical procedures in children Ideal for children with psychological benefitsIdeal for children with psychological benefits Careful planning with trained staffCareful planning with trained staff Children’s DSU or children only daysChildren’s DSU or children only days Pre admission visitsPre admission visits Children friendly surroundingsChildren friendly surroundings Duration of anaesthesiaDuration of anaesthesia Separate rooms with special facilitiesSeparate rooms with special facilities

Future trendsFuture trends Scope expected to expandScope expected to expand More invasive procedures on less fit patientsMore invasive procedures on less fit patients

Conclusion Conclusion

References References Al Fallouji M A R-Al Fallouji M A R- Post graduate surgery Post graduate surgery Badoe et alBadoe et al –Principles and practice of surgery –Principles and practice of surgery Russel R C G et al-Russel R C G et al- Short practice of Surgery Short practice of Surgery www.surgical-tutor.org.ukwww.surgical-tutor.org.uk www.gpnotebook.co.ukwww.gpnotebook.co.uk Dakum et alDakum et al –Cancellations of Urological day –Cancellations of Urological day

care surgeriescare surgeries