This is one of my recent presentations on ambulatory surgery in Minimal Access or Laparoscopy GI Surgery. How to plan and ambulate and discharge patients early. My Personal experience.
Circulatory Shock, types and stages, compensatory mechanisms
Ambulatory Laparoscopic Surgery
1. 30/03/2014, Gokak Dr M G Bhat
Consultant Surgeon
Minimal Access and Bariatric Surgery
Nova Specialty Hospital, Koramangala
Bangalore
Medical Director
Nova Medical Centers Pvt Ltd, India
Greetings From….
Dr. M G Bhat
MS, FRCS(England), FRCS ( Edinburgh), FICS
DMLE (Law), DMIRCSEd (Informatics)
3. 30/03/2014, Gokak Dr M G Bhat
1. Of, relating to, or adapted for walking.
2.
a. Capable of walking; not bedridden
an ambulatory patient.
b. Designed for or available to patients who
are not bedridden: ambulatory care;
ambulatory pediatrics..
am·bu·la·to·ry
4. 30/03/2014, Gokak Dr M G Bhat
Ambulatory Surgery
Office Surgery
Patient Recovers from Surgery and fit
to return home within few hrs
Ambulatory Surgery
Patient recovers from Surgery and fit to
return home the same evening without
overnight stay
The Day Care Surgery
Patient Recovers from Surgery and fit to
return home within a day or 24 hrs
Short Stay Surgery
Upto 72hrs
5. 30/03/2014, Gokak Dr M G Bhat
Changes Brought in by
Minimal Access Surgery
• Change in the Entire Concept of Recovery
• Fast Tracking of Surgery
• Early Recovery and Discharge
• No NG Tubes
• No Drains
• Early Feeding
• Early Mobilization
1973
1976
1991
2000
6. 30/03/2014, Gokak Dr M G Bhat
Short Stay Surgery
72hrs Stay
•Comfort Level & Flexibility
•Bariatric Surgery
•Spine Surgery
•Knee Replacements
•Bigger Surgeries in Fit Patients
•70% of all Surgeries
7. 30/03/2014, Gokak Dr M G Bhat
Concept :… Early Discharge
• Mobilse Early
• Feed Early
• Control Pain
• Safety & Quality
In 2008: 20% of the surgeries were day care in India.
In J Med Sci. 2008;3(3):101-116.
8. How to Discharge Early?
30/03/2014, Gokak Dr M G Bhat
• Select a Good Patient
• Select a Good Case
• Select Good Infrastructure Hospital
Good Risk Patient
Avoid Complex Case
Hospital with Good Support
Elective Cases
9. Pre Operative
30/03/2014, Gokak Dr M G Bhat
• Clinical Evaluation
• Investigations
• Assessment
• Planning
• Suitability
• Motivating
• Financials
• Fix Date of Surgery
10. Operation – Surgery Day
30/03/2014, Gokak Dr M G Bhat
• Admission in the morning
(patient comes prepared)
• Early Surgery ( No Waiting)
11. 30/03/2014, Gokak Dr M G Bhat
GI:
•Cholecystectomy
•Appendicectomy
•Hernia
•Diagnostic
•Gynecology
•Bariatric
•Colo Rectal
•Others
Others
• General
• Thoracic
• Urology
• Ortho
• ENT
• Interventional
• etc
MAS & Ambulatory Surgery
12. 30/03/2014, Gokak Dr M G Bhat
Stand
Alone
Day Care
Surgical
Centers
Part of a
Multi
Specialty
Hospital
Hospital
Only Few in India
• Good Infrastructure
• 25-30 beds
• 4 OR
• HDU
• Prepared to shift if required
13. 30/03/2014, Gokak Dr M G Bhat
Procedure <12hr 24 24-48 72
Lap Chole 236 210 24 2
Ing Hernia 110 98 12
Inc Hernia 36 3 27 2 4
Sleeve Resection 41 39 2
Appendix 7 4 3
Diagnostic Lap 6 6
Colorectal 6 2 4
Fundoplication 4 4
Gastric 4 2 2
Hellers 2 2
Spleen 1 1
Total 453 321 74 46 12
Personal Series: Lap in Nova Specialty Hospitals: 2010-13
14. *
Clinical outcomes Metric
Same day discharge ~60%
Superficial Post-
Surgical Infections
0.035%
Transfer to Other
Hospital (for
observation)
0.12% (31 nos.)
Fatalities* 0.01% (3 nos.)
Clinical outcomes
Urology, 1598, 5%
ENT, 4349, 14%
General Surgery,
11280, 37%Gynaecology, 4039,
13%
Opthomology, 1739,
6%
Orthopedics, 5100,
17%
Plastic surgery,
1233, 4%
Same day
discharge (<24
Hrs)
24-48 Hrs
discharge
Beyond48 Hrs
discharge
15%
25%
60%
Nova Audit : 2009-2013 : >30,000 Surgeries
15. Technical Consideration
30/03/2014, Gokak Dr M G Bhat
• Preop Motivation and Planning
• Anesthesia ( Quick Recovery)
• Analgesia
• No Sedation
• PONV (Post op nausea and vomiting)
• Early Ambulation
• Early Feeds
• Passing Urine
• Encouragement
• If all OK Discharge
16. 30/03/2014, Gokak Dr M G Bhat
Technical Consideration
Sensorcaine
Infiltration into wound
Instillation in Peritoneum
Abdominal Support in Incisional Hernias
18. Advantage:
30/03/2014, Gokak Dr M G Bhat
Early Discharge
Recovery at Home
Return to work
Ease and Convenient
Cost Saving
Less of INFECTION
Surgeons Comfort
19. Disadvantage
30/03/2014, Gokak Dr M G Bhat
Surgeon Mindset
Acceptance
Complications
General
Specific to surgery
Need for Shifting to Tertiary Care?
Return to center
20. 30/03/2014, Gokak Dr M G Bhat
Consultant Surgeon
Nova Specialty Surgery Hospital, Bangalore
Medical Director, Nova Medical Centers Ltd, India
Thank you
Dr. M G Bhat
MS, FRCS(England & Edinburgh), FICS, DMLE
(Law), DMIRCSEd (Informatics)