The document discusses ambulatory or day surgery. It defines day surgery as when a patient is admitted for a procedure and discharged within 12 hours. Day surgery has advantages over traditional inpatient surgery like lower costs, faster recovery, and less disruption to daily life. The document outlines patient selection criteria, common procedures performed as day surgery, and important considerations for the preoperative, intraoperative, and postoperative periods to facilitate day surgery and recovery.

1. AMBULATORY SURGERY
MANOJ VAIDYA

2. SYNONYMOUS TERMS-
 Ambulatory surgery
 Day-case surgery
 Day-care surgery
 Same-day surgery
 Come and go surgery

3. DEFINITION
 The original concept of day surgery was the admission and discharge of
a patient for a specific procedure within the 12hr working day.
 Day surgery is a PATIENT PATHWAY and NOT A SURGICAL PROCEDURE
 Day care surgery has been defined by the Royal College of Surgeons as
when the surgical day case patient is admitted for investigation or
operation on a planned non-resident basis and who nonetheless
requires facilities for recovery.

4. EXTENDED OR 23 HRS STAY POLICY
 Nowadays, many Day Units operate an ‘extended’ or ’23 hour’ stay
policy, which means that patients can stay in the Unit upto 23 hours 59
minutes and still be categorized as a day case.
 The ‘23-hour’ stay is determined by the day unit staff and is based on
the needs of individual patients, in order to ensure their safety

5. DAY CARE SURGERY & OUT PATIENT
SURGERY
 It is important to mention that day care surgery is different from out-
patient surgery in that the patients of day care surgery need some
degree of post-operative specialized nursing care necessitating post-
operative observation for a few hours.

6. FAST TRACK INPATIENT SURGERY
Fast track surgery involves the use of a coordinated, multi
disciplinary perioperative care
 plan to reduce complications,
facilitate earlier discharge from hospital
Faster recovery
Faster Return to daily activities after elective surgery

7. Why Day care surgery?
 Rising healthcare cost
 Emphasis on evidence-based practice
 Rising patient expectations

8. HISTORY
 The earliest reference for day care surgery is mentioned as
early as the beginning of the 20th Century by James Nicoll,
a Glasgow surgeon who performed almost 9000 outpatient
operations in children in 1903.
 Later, in 1912, Ralph Waters from Iowa, USA, described “The
Down Town Anaesthesia Clinic”, where he gave anaesthesia
for minor outpatient surgery.

9.  Ralph’s facility, which provided care for dental and minor surgery cases, is
generally regarded as the prototype for the modern freestanding ambulatory
(and office-based) surgery center.
 Surprisingly, there was little interest in ambulatory surgical care until the late
1960s,when the first hospital-based ambulatory surgery units were developed.
 Formal development of ambulatory surgery occurred with establishment of the
Society for Ambulatory Anesthesia & Surgery in 1984 and the subsequent
development of postgraduate subspecialty training programs

10. CURRENT SCENARIO
 By the end of 1990, 7 million elective operations in the United States
(over 30% of all elective surgical procedures) were performed on an
ambulatory basis.
 Currently, more than 60%of all elective surgery in USA is performed in
the outpatient surgical setting.
 In India though the exact data is unavailable, based on data from various
single centre studies, the day care surgery constitute only 10-15% of
elective surgical procedures.
Types of various surgeries in Day Care: A study from South India Amidyala Lingaiah1, Padam Venugopal2, K
Rukmini Mridula, Srinivasarao Bandaru1,5

11. OBJECTIVES OF AMBULATORY SURGERY
 To reduce waiting time for elective surgery
 To reduce inpatient admission
 To make surgery convenient and comfortable for the patient
 To reduce disruption of personal lives
 To reduce hospital-acquired infection
 To encourage early recovery and mobilization in a home environment
with their family
 To reduce cost of surgery

12. ADVANTAGES OF AMBULATORY SURGERY
PATIENTS’ ADVANTAGES
 Patient-centred
 Patient recovers in familiar environment
 Reduces complication
 Early return to daily living
 Reduce cost

13. HOSPITAL/ PHYSICIAN ORIENTED
 Increase bed availability
 Hospital can grow inpatient services
 Outpatient centre has greater efficiency & cost-effectiveness (increase
throughput)
 Health care cost reduction (25-75%)

14. DISADVANTAGES
 The need for a responsible person to oversee the day care patient at
home for the first 24-48 hours.
 The restriction of day case surgery to experienced senior staff;
 Extra work for the general practitioner in the postoperative period;
patients often ring them for advice or treatment.
 The cost-effectiveness of the unit is reduced when less complex cases
are dealt with on a day basis.

15. ORGANISATIONAL STRUCTURE

16. DAY SURGERY WORK FLOW

17. PATIENT AGREES
FOR SURGERY
SUITABLE
FOR DAY
Sx??
ALLOT
OPERATION DATE
ANAESTHETIC
CLINIC
OPTIMISE
THE
PATIENT IF
REQUIRED
&
REFFERALS
TO OTHER
DEPARTME
NTS
APPROPRIATE
FOR DAY CARE
SURGERY
DAY CARE SURGERY
PROCESS EXPLAINED
ALLOWED HOME
AWAITING SURGERY
PLAN
ELECTIVE IN
PATIENT
OPERATION
NO
YES

18. A TEAM MEMBER
REVIEWS DAY CARE LIST
1 TO 3 DAYS BEFORE
SURGERY
CALLS EACH PATIENT
CAN PATIENT
COME FOR
OPERATION?
PATIENT ARRIVES TO THE
HOSPITAL ON ALLOTED DAY
PATIENT REGISTERS AT DAY CARE
WARD & UNDERGOES PRE
OPERATION PROCESS
NO
PATIENT IS
ASKED TO VISIT
HOSPITAL FOR
NEW DATE

19. SURGEON AND
ANAESTHETIST REASSES
THE PATIENTS FITNESS
FOR SURGERY
SHIFTED TO THE
OPERATION THEATRE
DAY CARE WARD-
RECOVERY
POST OP REVIEW BY
ANAESTHETIST TO
ASSESS FITNESS FOR
DISCHARGE
POST OP REVIEW BY THE
SURGEON
DISCHARGE WITH
MDICATION DATE
FOR NEXT
APPOINTMENT
FIT
ADMIT IN
WARD
REGULAR WARD
CARE AND
DISCHARGE
NOT FIT

20. TEAM MEMBER
REVIEWS LIST OF POST
OPERATION
DISCHARGED
PATIENTS
CALLS EACH PATIENT
TO ASSESS DAY CARE
EXPERIENCE
ALL THE
CONVERSATION AND
DATA IS DOCUMENTED

21. TYPES OF DAY CARE SURGICAL CENTRES
Day Care Surgery can take place in various settings which are basically four
types in use
1. Hospital integrated unit
2. Hospital autonomous unit
3. Hospital satellite unit
4. Free standing unit
Each of these four has its own peculiar advantages and disadvantages

22. HOSPITAL INTEGRATED UNIT
 This unit provides a designated area to which patients are
admitted and from which they are discharged home and in
which preoperative evaluation and preparation are carried
out.
 The hospital operating rooms and recovery rooms are used
for both inpatients and Day Care Surgery patients.
HOSPITAL
Day
care
OT
RECO
VERY

23. HOSPITAL AUTONOMOUS UNIT
 This unit is totally self-sufficient.
 This type of unit is located within the hospital or
on the grounds of the hospital, but operates
totally independent of other portions of the
hospital.
HOSPITAL
DAY
CARE
DAY
CARE OT
RECOVERY
OT RECOVERY

24. HOSPITAL SATELLITE UNIT
 This is an autonomous facility which is sponsored and/or operated by
the hospital but located away from the campus of the hospital.
HOSPITAL
DAY
CARE

25. FREE STANDING UNIT
 This is an autonomous unit which is not geographically or
administratively part of any other health care facility
HOSPITAL
DAY
CARE
UNIT

26. INFRASTRUCTURE
LOCATION
 provided in an integrated set-up
 existing operating theatres,
 dedicated operating theatres/unit or a free standing dedicated
ambulatory care facility.

27. FACILITIES
 Registration counter
 Waiting room
 Assessment room
 Changing rooms
 Procedure rooms
 Operating theatres
 Pre and post- operative wards
 Recovery room
 Pharmacy

28. STAFFING
 Operating surgeon
 A consultant Anaesthesiologist, with special interest in day care surgery, shall be
responsible in developing protocols, policies, audit and clinical governance.
 Medical Officers
 Nursing Manager/Sister
 Theatre Scrub Nurses
 General Anaesthetic (GA) nurses
 Ancillary staff
 Recovery Ward Nurses

29. SELECTION CRITERIA AND SUITABLE
PROCEDURES FOR AMBULATORY SURGERY
I. Patient Criteria
II. Social Criteria
III. Surgical Criteria and Proposed Suitable Procedures

30. PATIENT CRITERIA
a) Health Status:
 ASA 1 and 2
 ASA 3 can be selected after consultation with the anaesthetic team
provided their disease is well controlled.
B) Age Limits:
 > 75 years and < 6 months should not be selected.
c) Physical Factors:
 no obvious difficult airway features
 BMI < 35 kgm-2

31. SOCIAL CRITERIA
 Patients/parents must be willing to cooperate and able to understand, comply
and cope with post-procedural instructions after receiving adequate
information and an opportunity to discuss any anxieties.
 Escort: who is responsible for patient’s care and able to accompany patient
home and supervised their recovery at home for a minimum of 24 hours.
 Transport: Suitable transport must be available to transport patient home post
surgery and also to come back to the hospital in event of emergency. Peferably
within 1hr distance from hospital.

32. SURGICAL CRITERIA
 Simple surgery < 90 minutes.
 minimal risk of postoperative complications e.g. haemorrhage or airway
compromise.
 minimal postoperative pain that can be controlled by simple analgesia.
 No special postoperative nursing required post surgery.
 Patient would not have prolonged immobility after the procedure.
 Rapid return of normal food and fluid intake possible after the procedure

33. COMMON DAY CARE PROCEDURES-
‘BASKET OF 25’
1. ORCHIDOPEXY
2. CIRCUMCISION
3. INGUINAL HERNIA REPAIR
4. EXCISION OF BREAST LUMP
5. ANAL FISSURE DILATATION & SPHICHTEROTOMY
6. HAEMORRHOIDECTOMY
7. LAPAROSCOPIC CHOLECYSTECTOMY
8. VARICOSE VEIN STRIPPING AND LIGATION
9. TRANSURETHRAL RESECTION OF BLADDER TUMOUR
10. EXCISION OF DUPUYTRENS CONTRACTURE
11. CARPAL TUNNEL DECOMPRESSION
12. GANGLION EXCISION
13. HYDROCELE
14. SURGERY FOR HALLUX VALGUS
15. REMOVAL OF METALWARE
16. EXTRACTION OF CATARACT
17. CORRECTION OF SQUINT
18. MYRINGOTOMY
19. TONSILLECTOMY
20. SUBMUCOUS RESECTION
21. OPERATION FOR BAT EAR
22. REDUCTION OF NASAL FRACTURE
23. D&C HYSTEROSCOPY
24. LAPAROSCOPY
25. TERMINATION OF PREGNANCY

34.  Due to advances in surgical and anaesthetic techniques many more
surgeries can now be managed as day care surgery
 THE BRITISH ASSOCIATION OF DAY SURGERY (BADS) has recommended
inclusion of another 50 procedures under the Name TROLLEY of
procedures.
 BADS now recommends Procedures like laparoscopic fundoplication,
laser prostatectomy, arthroscopy of knee & shoulder, thoracic
sympathectomy to be done on day case basis.

35. PREOPERATIVE ISSSUES

36. EVALUATION AND OPTIMISATION OF PRE-
EXISTING ORGAN FUNCTION
 Classifiction of functional capacity and optimization of organ function are
expected to reduce cardiovascular and other complications

37. ASSESMENT AND OPTIMIZATION OF
NUTRITIONAL STATUS
 Poor nutritional status is an independent risk factor for complications
after surgery
 Patients with Moderate and severe undernutrition benefit from
preoperative nutritional support preferably via enteral route for at least 7
days preoperatively
 Patients with less severe malnutrition including those with diminished
oral intake benefit from addition of few supplements o normal diet.

38. IMPROVEMENT OF PHYSICAL FITNESS
 Patients with poor baseline exercise tolerance and physical conditioning
are at increased risk of serious perioperative complications.
 The strategy of augmenting physical capacity in anticipation of an
upcoming stressor is termed as PREHABILITATION.
 Observational data suggests that simply instructing the patient to walk
for 30min daily in the preoperative period may be beneficial without the
need for a formal indivisualised exercise program.

39. PRE-OPERATIVE FASTING
 Current preoperative fasting guidelines recommend a 2 hour fasting for
clear liquids and a 6 hour fast for solids.

40. PREOPERATIVE INGETION OF ORAL
CARBOHYDRATE DRINK
Evidence supports that it may be beneficial to provide a drink
containing 100g of carbohydrate on the evening before
surgery and a second drink containing a further 50g upto 2-
3hrs before surgery.
This measure
improves preoperative feelings of thirst, hunger, anxiety and
reduces post operative insulin resistance and
reduces the catabolic stress response to surgery.

41. PATIENT EDUCATION
 For many patients impending major surgery represents a significant
psychological stress.
 There is evidence that emotional distress delays wound healing by
altering endocrine and inflammatory responses.
 In some centres patients are shown a short video outlining the aspects
perioperative care and outcomes which may be of concern to the
patient.

42.  Patient should be provided information about
 Benefits of day care program
 Goals for daily nutrition intake
 Early postoperative ambulation
 Discharge criteria
 Care at home and warning signs to seek medical care
 Expected hospital stay in the event of common complications

43. PRE OPERATIVE INSTRUCTIONS FORM

44. PREMEDICATION
 Apart from providing sedation and reducing anxiety, premedication plays
additional roles including
 Modulation of intraoperative haemodynamics
 Attenuation of postoperative side effects.
 ANXIOLYTICS- Fentanyl has a better profile for fast track surgery and
facilitates early hospital discharge.
 ANTICHOLINERGICS- Glycopyrrolate is preffered (0.3mg IV).
 BETA BLOCKERS AND ALPHA2 AGONISTS- with their anesthetic and
analgesia sparing effect, they maintain perioperative heamodynamic
stability and reduce post operative pain

45.  ANTACIDS AND H2 RECEPTOR BLOCKERS- H2 receptor blockers are given
on the day before surgery.
 Administration of anti-PONV medications such as dexamethasone and
ondansetron before or during induction of anaesthesia is recommended.

46. INTRAOPERATIVE ISSUES

47. ATTENUATION OF SURGICAL STRESS
RESPONSE
 The magnitude of noxious response can be reduced by perioperative
interventions that modify catabolic response
 PHARMACOLOGICAL- neural blockade with local anaesthetics,
glucocorticoids
 PHYSICAL (normothermia, MIS)
 NUTRITIONAL

48. ANAESTHETIC TECHNIQUES
General anaesthesia
Propofol is the IV agent of choice for induction
For maintainance anaesthesia desflurane and sevoflurane are used as
they fecilitate early recovery.
Short or intermediate acting muscle relaxants are used.
Sugamadex is a new compound which has shown to provide faster
reversal of non depolarising muscle relaxants.

49. REGIONAL ANAESTHESIA
REGIONAL ANAESTHESIA techniques (spinal, epidural and peripheral
nerve block) have several advantages over general anaesthesia like-
improved pulmonary function, decreased cardiovascular demand,
lower incidence of ileus and good quality of analgesia at rest and on
ambulation.
For faster recovery, minidose lidocaine (10-30mg), bupivacaine (3.5-
7mg) or ropivacaine (5-10mg) spinal anaesthetic techniques are
combined with potent opoid analgesic like fentanyl (10-25mcg) or
sufentanyl (5-10mcg).

50.  TIVA techniques using propofol are popular and offer
advantage of reduced post operative nausea and
vomiting.
 Caudal block is used to reduce pain in paediatric
patients for circumcision, herniorraphy, orchidopexy.
 Intra articular local anaesthetics are useful following
arthroscopy.
 Femoral and sciatic nerve block for knee surgery.
 Nerve blocks using portable infusion pumps which the
patient can continue at home.

51.  INCISIONAL LOCAL ANAESTHESIA
 INFILTRATION of local anaesthetic is used for surgical procedures like hernia repair,
anal surgery, breast procedures.
 Long acting local anaesthetic like bupivacaine should be injected into the wound.

52. MAINTENANCE OF NORMOTHERMIA
 Mild hypothermia elicits a stress response during recovery period.
 Maintenance of intraoperative normothermia with the use of active and
passive warming devices and aggressive post operative management of
shivering and residual hypothermia decreases incidence of wound
infection, myocardial ischeamia and protein breakdown.

53. FLUID MANAGEMENT
 Strategies that avoid both hypovolemia and post operative overload are
important in facilitating fast track recovery process.
 Intraoperative oesophageal Doppler monitoring can facilitate goal
directed fluid administration by targeting specific values for the cardiac
index.

54. MINIMIZATION OF INCISION AND MIS
 The incision should be as small as possible while allowing adequate
exposure
 Laparoscopic techniques must be used whenever possible.

55. POSTOPERATIVE ISSUES

56. MORBIDITY AFTER DAY SURGERY
MAJOR MINOR
Pulmonary embolism Pain
Respiratory failure PONV
MI Drowsiness
Haemorrhage Minor bleed
Unrecognised damage to viscous Infection
Headache

57. PAIN MANAGEMENT
 Pain remain the most common reason for delaying discharge after
ambulatory surgery.
 The use of peripheral nerve blocks and conduction blockade for major
and minor surgical procedures in combination with adjuvants provides
excellent analgesia.
 The current strategy for post operative analgesia involves a combination
of regional anaesthesia, MIS, and non opoid pharmacological
interventions.

58. POST OPERATIVE NAUSEA AND VOMITING
 PONV continues to be a common complication of surgery with an
overall incidence of 20 to 30 %.
 PONV delays discharge and is the leading cause of unanticipated
hospital admission in ambulatory surgical patients.

59. ILEUS
 ILEUS causes discomfort and delays oral food intake thereby prolonging
recovery and duration of hospitalisation.
 Other interventions like early feeding, prokinetics like metoclopramide,
prophylactic nasogastric intubation, have minor effect on occurance of
ileus
 Use of opioids should be avoided.
 Early mobilisation should be encouraged.

60. POSTOPERATIVE FEEDING
 The protocol should be tailored in accordance with the procedure being
done and by the patients tolerance.
 For most abdominal surgeries, patients are encouraged to take liquids
on the night following the operation with light solids given on the
morning of post op day 1 and normal diet initiated on post op day 2.

61. MOBILISATION
 Emphasis on ‘OUT OF BED DAY 0’ strategy
 POST OPERATIVE bed rest should be discouraged.
 Structured post operative mobilization is an important component of
fast track surgery protocols.
 Patient should be given written instructions that include specific goals for
each day.
 Adequate pain control also helps in early mobilisation.

62. USE OF DRAINS AND CATHETERS
 DRAINS and catheters impede independent mobilisation.
 Reviews of randomised trials do not support the use of routine
prophylactic drainage for thyroid surgery, cholecystectomy, colorectal
anastomosis.

63. DISCHARGE CRITERIA
 Oral intake is tolerated
 Pain is well controlled
 Voiding without difficulty
In deciding when patients have recovered enough to allow their safe
transfer to an ambulatory surgical unit (ASU), or Phase II recovery, the
PADSS and Aldrete scoring system has been used

64. POST ANAESTHESIA DISCHARGE SCORING
A TOTAL PADSS SCORE >/= 9 IS
CONSIDERED FIT FOR DISCHARGE

65. POST DISCHARGE FOLLOW UP
 PATIENT SHOULD BE ABLE TO Contact the team member of the day care surg team
should any problem like fever, wound redness, discharge arise.
 A follow up telephone call should be made 24 to 36 hrs after the patient goes home.
 Patient should visit the clinic between post operative day 7 and 10 and then seen again
at 1 month after the operation
 Patients are given specific written instructions about the recovery course.

66. BARRIERS
 Failure to recognize daycare surgery as priority
- clinician’s preference
- patient’s attitude
 Lack of financial incentives
 Lack of specialized facilities
 Poor management and organization of outpatient surgery unit

67. PROBLEMS FACED IN DEVELOPING
COUNTRIES
 lack of awareness in the patient population,
 poor communication and transport,
 poor facilities for proper training of doctors in day surgery specialty and
sidelining the surgical specialties.
 Health Ministries in favour of other programmes particularly those
related to HIV/AIDS, Malaria and Tuberculosis as well as maternal and
child health.

68. AUDIT
 Effective audit is an essential component of assessing, monitoring and maintaining the
efficiency and quality of patient care in day surgery units.
 Routine collection of data regarding patient throughput and outcomes

70. EXTENDED RECOVERY CENTRES AND LIMITED
CARE ACCOMMODATION (MEDI MOTELS,
HOSPITAL HOTELS)
 Ideally, all ambulatory patients should go home the day of surgery, with responsible
escort to home.
 The concept of extended (Overnight) recovery after ambulatory surgery and Limited
Care Accommodation (Medi Motels) or hospital hotel is being promoted in some
countries for day care surgery patients who do not fulfil the criteria for discharge home.
 A hospital hotel is defined as a place close to the hospital, where the patient is
supposed to have the same facilities and staffing as in an ordinary hotel, but where
there are somewhat better facilities for handling unanticipated medical problems.

71. DAY CARE SURGERY IN SPECIAL
ENVIRONMENTS
 Awake craniotomy for tumour resection has been performed as a day
case in the UK.
 In the interventional X-ray suite, uterine artery embolisation is a day case
procedure, whereas endovascular aneurysm stents and several other
procedures are appropriate for a short stay approach.
 All the accepted standards for delivery of anaesthesia, assistance for the
anaesthetist, minimal monitoring and the availability of appropriate
recovery (post-anaesthesia care unit (PACU)) facilities should be achieved

72. INTRODUCING NEW PROCEDUE TO DAY
CARE
 The successful introduction of new procedures to day surgery depends
on many factors, including the procedure itself and surgical, nursing and
anaesthetic colleagues.
 It is important to evaluate the procedure while still performing it as an
overnight stay and identify any steps in the process that require
modification to enable it to be performed as a day case,
e.g.
timing of postoperative X-rays,
modification of intravenous antibiotic regimens,
physiotherapy input and analgesia protocols

73. INTRODUCING NEW PROCEDUE TO DAY
CARE
 A multidisciplinary visit to another unit that may be already performing
the procedure on a day case basis may be helpful.
 Initially limiting the procedure to a few colleagues (surgeons and
anaesthetists) allows an opportunity to evaluate and optimise techniques
and to implement step changes so that the patient can be discharged
safely

74. DAY CARE SURGERY IN INDIA
 Dr. M. M. Begani is the founder president of the indian association of day case surgery
 He is pioneer in promoting day care surgery and day care surgery centres in india.
 Nova medical centres- a chain of day care units.

75. REFERENCES
 ACS Text book of surgery 7th edition
 Bailey & Love’s text book of surgery 26th edition
 SABISTON Text book of surgery 20th edition
 Schwartz principles of surgery
 Smith and Atkinheads text book of anaesthesia 6th edition.

76. THANK YOU