This document discusses pediatric day surgery (PDS) and day case laparoscopic surgery (DCLS) at Apollo Children's Hospital in Chennai, India. It provides details on: the history and increasing use of PDS; patient selection criteria for DCLS; anesthesia and surgical protocols used; a retrospective analysis of 85 DCLS cases with no reported complications; and conclusions that DCLS can be performed safely without compromising patient care when a multidisciplinary team approach and clinical care pathway are followed.

1. Dr Prakash Agarwal
Dr R.K.Bagdi
Dr Raghavendran
Apollo Children’s Hospital,
Chennai.

2.  Day-care surgery, is the performance of elective
operative procedures under general anesthesia
in patients who are admitted to and discharged
from hospital the same day.
 The patient receives the same hospital treatment
with regard to care, safety and medical records
as would an inpatient.

3.  Paediatric Day surgery – Nicholl (1909)
 In recent years - increasing amount of surgery on
children on a day stay (ambulatory or outpatient)
basis.
 Children make excellent candidates for day case
surgery-healthy, free of systemic disease and typically
require straight-forward, minor or intermediate surgical
procedures.
 Introduction of Laparoscopic day-case in Pediatrics
since 2003.

4.  Clinical outcomes of Paediatric laparoscopic
surgery in day care
 Cost-effectiveness
 Increased efficiency is not obtained at the
expense of the overall quality of the treatment

5.  It lowers the cost of hospital care
 Increases the availability of hospital bed.
 It has been shown to be safe, with as few
complications and as short recovery periods as
traditional inpatient surgery.
 Early ambulation
 Decreased probability of acquiring an in-hospital
cross-infection
 Decreased separation anxiety, less emotional stress
for the child and reduced disruption of the family unit.

6. • INCLUSION CRITERIA
- ASA Gr I & II
- Staying close to Hosp
- Willing to return to hosp in case
of problem
- Parents able to understand the
instructions well
• EXCLUSION CRITERIA
- Co-morbid conditions
- Raised LFT
- Staying far from the hospital
- Insurance company not
agreeing for Day care surgery
- If a second surgery is planned
•The role of DCLS in pediatric practice is yet to be
established.
•There has been only two reports on DCLC in children

7. Referral of children with presenting illness to outpatients clinic
History and examination & Informed consent for laparoscopic procedure
Outpatient CBC, U&Es, LFTs and abdominal ultrasound scan
Inclusion criteria for DCLS met-DCLS
scheduled
Inclusion criteria for DCLS not met-
DCLS not appropriate
Admission on morning of procedure and cases
posted in the list
Anaesthetic/Analgesia
protocol
PONV prophylaxis and
management
Nursing Protocol

8. CONDITIONS NUMBER OF CASES REMARK
LAPAROSCOPIC
CHOLECYSTECTOMY
15 13 – TAP BLOCK
02 – PORT SITE
LOCAL INFILTRATION
LAPAROSCOPIC
ORCHIDOPEXY
SINGLE STAGE – 24
TWO STAGE – 4 + 4 32
PORT SITE LOCAL
INFILTRATION
LAPAROSCOPIC
HERNIA
MALES - 22
FEMALES -12 34
PORT SITE LOCAL
INFILTRATION
LAPAROSCOPIC
VARICOCELE LIGATION
4 PORT SITE LOCAL
INFILTRATION
Total 85

9. • Data relating to the cases were collected
prospectively and clinical outcomes were audited
• All patients were seen in the outpatient clinic before
DCLS and explained regarding the procedure.
• Informed consent was obtained.
• Blood tests and an abdominal ultrasound scan
were requested & anesthesist review.
• Patients were admitted electively on the morning of
the procedure and
• Underwent a Lap procedure on the list.

10. ANESTHESIA
 Induction of anesthesia was
with propofol. All patients
were ventilated via an
endotracheal tube with air,
oxygen, and sevoflurane.
 Prophylactic antiemesis –
ondansetron
 Analegsia – Tap Block
SURGERY
 A standard three / four-port
technique was used
 5mm /10mm at the umbilicus,
2 X 5mm at the iliac fossa
 CO2 insufflation below
12mmHg and rate from 1-3
L/min.
 At the end of, an attempt was
made to evacuate all CO2

15.  Early mobilization was encouraged
 Postoperative feeding regime from liquids to light diet
for 72 hours
 Pain was assessed by the Nurse and scored using the
Wong and Baker FACES pain rating scale.
 Patients were reviewed in the afternoon by the
anesthetic team and jointly by the surgical and the
nursing team and a decision was made regarding
discharge
 Final decision regarding discharge made jointly by the
patients’ families and the nursing team.

16. • Normal temperature,
pulse and blood
pressure,
• Tolerance of fluid and
light diet,
• Adequate pain
control, comfortable
mobilization, and
patient/carer
satisfaction with
discharge.

17.  Jan 2010- March 2014 = 85 patients
 M:F = 68:17
 Age = 2-16 years (11.8 years)
 Ultrasound: Done preoperatively to diagnose
cholelithiasis in all patients who underwent lap
chole & normal internal organs for patients with
hernia and UDT.

18. • Duration of Surgery- 35-70 min (Avg 57 min)
• Intra operative problems - Nil
• Post operative problems - Nil
• Conversion to open - Nil
• Pain score at Discharge – 3/10
• PONV - Tolerable
• Pain score on follow up – 2/10 (R shoulder tip pain
in 4pt of Chole)
• Patients with TAP block were more comfortable.

19. • Admission on the day before the procedure was
unnecessary
• Explanation of the procedure and discharge policy to
the families in the outpatient setting was extremely
important in acceptance of having a major procedure
performed in an ambulatory setting.
• Day care surgery is less expensive than inpatient
surgery.
• The use of Transversus abdominis plane (TAP) offers
excellent pain relief in day care setting.

20.  Should not be underestimated.
 Requires a major shift away from a traditional
conservative approach with regard to introduction of
enteral feeds, mobilization, and pain management.
 Introduce an element of balance to the decision
regarding patient discharge

21. • Rigorous patient selection is a prerequisite for
the success of DCLS.
• A cornerstone of successful DCLS practice is
adequate pain management. The use of
transversus abdominis plane block
demonstrated huge benefits.
• No PONV due to routine combination
intraoperative antiemetics, minimization of the
use of long acting intravenous opioids, and a
strict dietary regime

22. • DCLS in children is feasible in the majority of patients
requiring a sole procedure
• Performed with excellent results without compromising
patient safety.
• DCLS is cost effective
• A multidisciplinary team approach
• Adoption of a clinical care pathway
• Adequate pain management and avoidance of PONV
are a prerequisite for success.