Day surgery, also known as ambulatory surgery, involves performing surgical procedures on patients who are admitted and discharged within 12 hours without an overnight hospital stay. Day surgery offers advantages for both patients and healthcare systems by reducing disruption to patients' lives and providing significant cost savings. A variety of medical, social, and surgical criteria are used to determine patient eligibility for day surgery to minimize risks and ensure safe recovery at home. Successful day surgery requires thorough preoperative patient assessment, optimized anesthesia and postoperative pain management, and monitoring to prevent complications.

1. Day Care Surgery

2. DAY SURGERY
• The delivery of a surgical procedure on a day case basis offers advantages in providing
significant benefits for both patient and healthcare providers.
• The removal of an overnight stay causes less disruption to the patient’s domestic and social
situation, and provides significant financial savings to the hospital.
• In resource-rich countries, day surgery is now an integral component of healthcare delivery,
while in resourcepoor countries, day surgery is increasing in popularity due to patient
preference and healthcare reorganisation.

3. • Day surgery is defined as the admission and discharge of a patient for a specific procedure
within the 12-hour working day.
• Where a patient requires an overnight admission, then the term ‘23 hour stay’ should be used.
• Success in day surgery requires each component of the pathway to be safe and efficient and to
be performed in sequence.
Unplanned overnight admissions are minimized by ensuring that:
• the patient is informed and fit for the procedure;
• the procedure itself is achievable as a day case;
• the procedure is scheduled early on the operating list to allow safe recovery and discharge;
and

4. • the home environment can support a postoperative ambulatory patient.
Definition of terms used in ambulatory surgery
• Outpatient surgery: not admitted to a ward facility
• Procedure room surgery: surgery not requiring full sterile theatre facilities
• Day or same-day surgery: admitted and discharged within the 12-hour day
• Overnight stay: 23-hour admission with early morning discharge
• Short-stay surgery: admission of up to 72 hours

5. SELECTION CRITERIA
• Medical criteria
Age
• There is no upper age limit. The physiological health of the patient is a superior determinant
of day surgery success.
Medical: use physiological rather than chronological age
• ASA status over 2 requires careful review
• Provided that the BMI is under 40, this alone is not a contraindication

6. • Social: a responsible adult carer must be available for the first 24 hours, for the elderly and
patients at risk of covert bleeding
• home conditions need to be suitable ability to contact hospital in an emergency
• Surgical: operations up to 2 hours recognised day surgery procedures ability to eat and drink
within a reasonable timescale

7. Comorbidity
• Day surgery units traditionally use the American Society of Anaesthesiologists (ASA)
Classification, which is a crude evaluation of chronic health Stand-alone units often confine
their criteria to ASA 1 and 2 patients, while ASA 3 patients are more suitable for hospital-
integrated units.
• Patients with significant respiratory or cardiovascular disease should be reviewed by an
anaesthetist before being accepted for day surgery.

8. Diabetes
• The incidence of diabetes is increasing worldwide. Patients with well-controlled Type 1 and
Type 2 diabetes are good candidates for the well-managed day surgery pathway.
• Control can be assessed by measuring their HBA1c, with a level of below 8.5% indicating
good control.
Epilepsy
• A diagnosis of epilepsy does not contraindicate day surgery.
• Patients who have well-controlled epilepsy should be managed as normal patients, though it is
important to ensure that their regular medication is not omitted in the preoperative period.

9. Obesity
• The body mass index (BMI) is calculated as weight in kilograms divided by the square of
height in metres (kg/m2) and obesity is defined as a BMI >30.
• Traditional guidelines are conservative about obesity due to fears of intra- and postoperative
complications.
• Although there is an increased incidence of non-serious respiratory complications
intraoperatively and in the immediate postoperative recovery period, the course of these
patients is otherwise uneventful.

10. Anticoagulants
• Patients are generally on oral anticoagulants due to atrial fibrillation, previous
thromboembolism or because they have a metal heart valve.
• It is therefore important to review these patients carefully before deciding to discontinue their
anticoagulant for their operation.
Social criteria
• Safe and comfortable discharge home requires the patient to be accompanied by a responsible
and physically able adult.
• A journey time to home of 1 hour or less is advocated, but the comfort of the journey rather
than the time involved is more relevant.

11. Surgical criteria
• Patients undergoing procedures up to 2 hours in duration can safely undergo day surgery with
modern anaesthetic techniques.
• The degree of surgical trauma is an important determinant of success, with entry to
abdominal and thoracic cavities confined to minimal access techniques
• Whatever the procedure, the main requirement is that there is suitable control of pain and the
ability to drink and eat in a reasonable timescale.

12. PREOPERATIVE ASSESSMENT
• The evaluation and optimisation of a patient’s fitness for surgery is known as preoperative
assessment and is best performed by a specialist nursing team with support from an
anaesthetist with an interest in day surgery.
• All elective surgical patients should be initially regarded as suitable for day surgery until
proved otherwise. The assessment should be performed early in the pathway to allow time to
optimize health problems before surgery.
• The consultation consists of a basic health screen to include the measurement of BMI, blood
pressure and an assessment of past medical history with current medication recorded.

13. • Appropriate investigations are performed to ensure the patient is fit for surgery.
• The patient and/or their carer should be given verbal and written information regarding
admission, operation and discharge.
PERIOPERATIVE MANAGEMENT
Scheduling
• With dedicated day surgery lists, major procedures should be scheduled early on morning lists
to allow maximum recovery time.
• When the list is in the afternoon, the allocation of local or regional anaesthetic cases later in
the day helps reduce unplanned overnight admissions.

14. Anaesthesia and analgesia
• Successful day surgery anaesthesia requires a multimodal approach to analgesia, while
ensuring patients are given optimal dosages of anaesthetic agent .
• The agents used matter less than the skill of the person providing anaesthesia.
• Multimodal analgesia starts in the preoperative period and unless contraindicated, patients
should receive full oral doses of paracetamol and a non-steroidal anti-inflammatory drug,
such as ibuprofen.
• Intraoperative anaesthesia can be maintained by any of the traditional inhalational agents.
Total intravenous anaesthesia (TIVA) techniques using propofol are also popular and offer the
advantage of reduced postoperative nausea and vomiting (PONV).

15. • Pain levels should be routinely assessed in the postoperative recovery area.
• Further doses of paracetamol, fentanyl or low doses of morphine can be used to ensure that
patients are comfortable prior to return to the ward.
Postoperative complications
• The range of postoperative complications is no different from inpatient surgery.
• However, the fact that the patient is discharged home within a few hours of surgery requires
proactive monitoring in the immediate postoperative period.
• Reactionary haemorrhage is uncommon but requires careful consideration following
tonsillectomy and laparoscopic procedures.

16. • Reactionary haemorrhage following tonsillectomy occurs within the first 6 hours and these
patients should be monitored for this period.
• The danger in laparoscopic surgery is covert haemorrhage, especially in young fit patients
who can lose over 15% of their blood volume before showing any cardiovascular signs of
hypovolaemia (tachycardia and hypotension).

17. ELECTIVE DAY SURGERY
• For some surgical specialties, over 90% of their elective workload can be achieved in day
surgery. As a result, teaching and training now routinely occurs on day surgery lists but
requires structure and close supervision.
• As the spectrum of procedures has increased and become more challenging, many surgeons
have increased their involvement in day surgery.
• This is important because safe and efficient day surgery demands the competence and skill of
an experienced surgeon.

18. • The risk of postoperative haemorrhage occurring once the patient has returned home is often
stated as a major reason to keep the patient in hospital overnight, especially where the
abdominal or thoracic cavities have been entered.
• Reactionary haemorrhage commonly occurs in the first 4–6 hours after surgery, but the
patient is unlikely to have been discharged home within this time period.
• It may be caused by slippage of a ligature or displacement of blood clot, precipitated by a rise
in blood pressure, coughing or increased mobility.
• Postoperative monitoring of vital signs should alert the recovery team to any underlying
bleed.

19. • Good surgical technique requires minimal tissue traction or tension and good haemostasis.
• In day surgery these attributes are even more important.
• Volume procedures where 40% or more should be performed on a day case basis.
• Abdominal - Excisional/treatment of anal lesions, haemorrhoidectomy, primary and recurrent
inguinal/femoral herniae, laparoscopic cholecystectomy, laparoscopic fundoplication,
pilonidal sinus surgery
• Breast - Excision/biopsy breast lesion, sentinel node excision
• Genitourinary - Laser prostatectomy, orchidectomy, circumcision, excision of
hydrocoele/varicocele/epididymis

20. • Orthopedic - Dupuytren’s fasciectomy, carpal tunnel release, therapeutic arthroscopy of knee
or shoulder, bunion operations, removal of metalwork
• Vascular - Varicose vein procedures, thoracoscopic sympathectomy

21. EMERGENCY DAY SURGERY
• Many emergency surgical procedures are minor and non-life threatening, and traditionally
have been considered low priority for surgical intervention.
• Many of these cases, such as incision and drainage of abscesses, can be safely discharged
home after their initial evaluation in the emergency department.
• They are provided with adequate analgesia and scheduled to return to the hospital at an
appointed time the following day, suitably starved for their operation.
• This allows same-day discharge for minor emergency procedures.

22. • If performed early in the day, the surgery rather than the pathway, may be defined as ‘day
case’.
• Some patients may, by chance, achieve a true day case pathway with admission, operation and
discharge in the same day, provided they are admitted early in the day, there is no diagnostic
delay and a theatre slot is available.

23. DISCHARGE
• The assessment of when a patient is fit for discharge is best performed by trained day surgery
nurses using strict discharge criteria While postoperative review by the surgical team is
encouraged, the discharge should not be delayed by failure of their timely attendance.
• A suitable supply of analgesics for the management of pain should be provided.
Discharge criteria
• Vital signs stable for at least 1 hour
• Correct orientation as to time, place and person
• Adequate pain control with supply of oral analgesia
• Understands how to use oral analgesia supplied

24. • Ability to dress and walk where appropriate
• Minimal nausea, vomiting or dizziness
• Has taken oral fluids
• Minimal bleeding or wound drainage
• Has passed urine (if appropriate)
• Has a responsible adult to take them home
• Written and verbal instructions given about postoperative care
• Knows when to come back for follow-up (if appropriate)
• Emergency contact number supplied

25. THANK FOR YOUR ATTENTION