Surgery Resident clinical seminar on day case surgery presented to the department of surgery, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State

1. Day Case Surgery
By
Dr Baribote O. S. (MBBS)
3rd March, 2023

2. Outline
Introduction
Terminology, abbreviations and definitions
History of day case surgery (DCS)
Advantages/disadvantages
Models of DCS
Desirable features of DCU
Work flow
Common day case procedures
Selection criteria

3. Outline contd
Preoperative assessment and Management
Intraoperative management
Post operative recovery and management
Discharge criteria
Follow-up
Complications
Challenges in the developing world
Conclusion
References

4. Introduction
Day case surgery is defined as admission and discharge of a patient for
a specific procedure within the 12-hour working day
According to Royal College of Surgeons of England
• a patient who is admitted for investigation or operation on a planned non-
resident basis and who nonetheless requires facilities for recovery
• The whole procedure should not require an overnight stay in a hospital bed
Day case surgery is an increasingly vital part of elective surgery
worldwide
Day surgery is
• a high-quality,
• safe and cost-effective approach to surgical health care,
• enjoying a high rate of patient satisfaction

5. Introduction contd
• Accounts for over 50% of elective surgeries in the
UK and
• over 60% in the US and Canada
According IH Abdulkareem (2011) - DCS
• Such exact figures can not be quoted but it is
growing in popularity in Nigeria
• Due to its twin benefits of convenience and cost-
effectiveness
Nigeria

6. Terminologies
Terminology Synonyms and definitions
Day surgery (DS) Ambulatory surgery (AS), same-day surgery, day only
Day surgery Centre
Ambulatory surgery centre (ASC), day-surgery unit
(DSU), ambulatory surgery unit, day clinic
A centre or facility designed for the optimum
management of an ambulatory surgery patient
Extended recovery
23 hours, overnight stay, single night, Treatments
requiring an overnight stay before discharge
Short stay
Treatments requiring 24–72 hours in hospital before
discharge
Outpatient
A patient treated at a hospital who is not admitted for a
stay of 24 hours or more
Inpatient
A patient admitted into a hospital, public or private, for a
stay of 24 hours or more

7. Historical perspective
He laid the foundations for modern
day case surgery at the turn of the
20th century
He work performed a total of 9000
surgeries as day cases (1900 – 1908)
and reported in 1909
His work was motivated by
• financial benefits,
• concerns over hospital infection rates and
• a lack of hospital beds
James Henderson Nicoll
(1864 – 1921)

8. His report led to little immediate progress, mostly owing to
professional inertia and opposition (Jarrett and Staniszewski 2006)
DCS has experienced tremendous growth following introduction of
• Short acting anaesthetic agent and
• Improved surgical techniques
Eric Farquharson popularize DCS with his report of 458 adult
hernia repair under LA in 1955
British association of day case surgery (BADS) – 1989
International Association of Ambulatory Surgery (1995)

9. Advantages of DCS
Reduced costs
More efficient high-volume throughput of patients
In-patient beds freed for major and emergency surgery
Fewer cancellations on the day of surgery
Low incidence of serious postoperative morbidity
Reduced thrombo-embolism and hospital-acquired infections
Minimal disruption of patient’s life
Early return to work and normal activities
Patients, especially children prefer it
Day surgery is cost-effective for primary care trusts

10. Disadvantages of DCS
High initial cost of setting up day
surgery units
Good organization, management
and training required

11. Models of DCS
Day surgery is carried out in one of four organizational
models
Whatever model that is adopted should take account
of both
• local needs
• and existing surgical provision and configuration of facilities.
Models
• Hospital integrated facilitiy
• Self-contained unit on hospital site
• Free standing self contained unit
• Physician’s office based unit

12. Desirable features of DSU
It should be self-contained, with its own reception, ward,
theater(s), and recovery area
Adjacent parking space should be available
It should be well laid out with good patient flow
DSUs should be equipped to the same high standards as in-
patient wards and theaters
Beds: Theater ratio should be related to specialities
There should be flexibility for changing needs
Protocols for patient selection, analgesia, and discharge criteria
should be available

13. Desirable features of DSU contd
There should be good record keeping
Support services should be readily available
Trained experienced staff should be at hand
Consultant-led anesthesia and surgery
Organized training with close supervision of trainees
Clinical director should be in overall charge
There should be teamwork between groups
Liaison with community services

14. Elective day surgery pathway

15. Common procedures done in DCS
• General Surgery
– Inguinal hernia repair
– Excision of breast lump
– Anal fissure dilatation
or excision
– Haemorrhoidectomy
– Laparoscopic
cholecystectomy
– Varicose vein stripping
or ligation
• Urology
– Orchidopexy
– Circumcision
– Transurethreal resection of
bladder tumour
– Ureteroscopy, cystoscopy
– Hyrocele, spermatocele

16. Procedures contd
• ENT
– Reduction of nasal fracture
– Operation for bat eat
– Myringotomy
– Tonsillectomy
– Laryngoscopy, nasal polyp
• Ophthalmic surgery
– Extraction of cataract
– Correction of squint
– Trabeculectomy
– Vitreoretinal, corneal surgery

17. Procedure contd
• Orthopaedic
– Excision of duputrens
contracture
– Carpal tunnel decompression[
– Ganglion excision
– Surgery for hallux valgus
– Arthroscopy
– Nerve and tendon repair
• Gynaecology
– D&C
– Hysteroscopy
– Termination of pregnancy
• Plastic surgery
– Augmentation mammoplasty
– Rhinoplasty, blepharoplasty

18. • Recommended a trolley of procedures
• Contains about 50 procedures such as
• Laparoscopic fundoplication
• Laser prostatectomy
• Arthroscopy of knee and shoulder
• Thoracic sympathectomy
• to be done on a day case basis
British association of Day Surgery (BADS)

19. Selection criteria
Patient selection criteria for day surgery falls into three main
categories
• Social
• Medical and
• Surgical
It is recommended
• that a multidisciplinary approach,
• with agreed protocols for patient assessment, including inclusion and
exclusion criteria for day surgery,
• should be agreed locally between surgeons and the anaesthetic
department

20. Social criteria
Consent: The patient must
• understand the planned procedure and postoperative care and
• give informed consent to day surgery
Escort:
• A responsible and physically able adult should accompany patient home
Transport:
• A journey time of 1 hour or less as well as comfortable means of transportation
Home:
• Comfortable home facilities with appropriate toilet facilities
Communication
• Means of communication with hospital
• Via telephone or setup of virtual ward

21. Medical criteria
Patient’s fitness for day surgery should be
judged by functional assessment at the time
of preoperative assessment
Age:
• Elderly - no upper age limit
• Paediatrics: Full-term infants over 1 month but in ex-
premature infants, a higher age limit (60 weeks post-
conceptual age) is advised owing to the increased risk
of postoperative apnoea

22. Medical criteria contd
Patients with well controlled chronic medical conditions
such as
• diabetes, asthma, or epilepsy
• are suitable for day surgery.
Obesity is not a contraindication for day surgery
• BMI up to 40kg/m2 for surface procedures and 38kg/m2 for
laparoscopic procedures are acceptable and achievable in advanced
units
Anticoagulant: patients with atrial fibrillation, hx of PTE
must be reviewed with a cardiologist if surgery requires
discontinuation of anticoagulation

23. Surgical criteria
Minimal physiological trespass
The procedure(s) must not be associated with excessive blood
loss or fluid shifts
There should be very low risk of serious postoperative
complications like bleeding or airway obstruction
Duration of surgery up to 1 hour, with a maximum of 2 hours
Pain must be controllable with oral analgesics after discharge
The patient should be reasonably ambulant afterwards

24. Preoperative assessment
Successful day surgery outcomes require good
preoperative preparation.
This has three essential components
• Education of patients and caregivers about day surgery
pathways.
• Helping patients to make informed decisions by providing
verbal and written information regarding planned procedures
and postoperative care.
• Identification of any medical risk factors and optimizing
medical conditions before surgery

25. • establish diagnosis,
• establish comorbid states and current medication and
• assess for fitness to surgery
Detailed history and physical examination is
done to
• FBC
• EUC
• Urinalysis
• Clotting profile
• And other specific investigations to arrive at diagnosis
Appropriate investigations
Preoperative assessment contd

26. Patient education and consent
Patient should be provided information about
• Benefits of day care program
• Goals for daily nutritional intake
• Early postoperative ambulation
• Discharge criteria
• Care at home and warning signs to seek medical care
• Expected hospital stay in the events of common complications
A written informed consent is obtained
Verbal instructions should always be accompanied by
clear written information

29. Schedule
•Dedicated DCS list
•Mixed inpatient and DCS
list
The theatre list

30. Premedications
• Benzodiazepines
• Antiemetics
• H2 antagonists

31. Intraoperative management
Anaesthetic techniques
The key requirements of a day surgery
anaesthetic agent include:
•rapid onset and offset of anaesthesia with clear-
headed emergence,
•minimal postoperative nausea and vomiting (PONV),
dizziness, or drowsiness,
•rapid return to full cognitive functions

32. Anaesthetic technique contd
• Propofol is the IV agent of choice for induction
• For maintenance anaesthesia, desflurance and
sevoflurane are used as they facilitate early recovery
• Short or intermediate acting non depolarizing
muscle relaxants are used e.g cisatracuruim,
mivacurium
• Sugamedex is a new compound which has shown to
provide faster reversal of non depolarizing muscle
relaxants
General anaesthesia

33. Anaesthetic technique
• Spinal, epidural and peripheral nerve bloock have
several advantages over GA
• Improved pulmonary function
• Decreased cardiovascular demand
• Lower incidence of ileus
• Good quality of analgesia at rest and ambulation
• For faster recovery,
• Minidose lidocaine (10-30mg), bupivacaine (3.5-7mg),
or ropivacaine (5-10mg) spinal anaesthetic techniques
are combined with potent opioid analgesic like
fentanyl (10-25mcg)
Regional anaesthesia

34. Other anaesthetic techniques
Intraarticular LA are useful following arthroscopy
Femoral and sciatic nerve block for knee surgery
Incisional local anaesthesia
Infiltration of LA is used for procedures like Hernia repair, anal
surgery and Fibroadenoma excision
Long acting LA like bupivacaine should be injected into the wound

35. Other intraoperative management
• Mild hypothermia can elicits a stress response during
recovery period
Maintenance of normothermia
• The routine use of adequate i.v. fluids can enhance a
patients feeling of well-being and reducing PONV
Adequate Fluid care
• Small but enough to allow adequate exposure
• Laparoscopic techniques must be used whenever possible
Incision

36. Post operative recovery
Admitted into Phase I recovery:
Early recovery, from end of anaesthesia until the
return of protective reflexes and motor function
Acute symptoms such as pain and nausea and
vomiting should be treated quickly with simple
oral analgesia supplemented by short-acting
opiates if required (e.g. i.v. fentanyl)

38. Post operative recovery contd
•Admitted into this area when the criteria for
post anaesthesia discharge are met
•During this time, patient is nurse and observed
to achieves the criteria for discharge
•Upon achieving the milestones, patient is
discharge home
Phase II recovery:

39. Discharge check list
Criteria Yes No
Vital signs stable
Orientated to time, place, and person
Passed urine (if applicable)
Able to dress and walk (where appropriate)
Oral fluids tolerated (if applicable)
Minimal pain
Minimal bleeding
Minimal nausea/vomiting
Cannula removed
Responsible escort present
Has carer for 24 h postop
Written and verbal postop instructions

40. Criteria Yes No
Knows who to contact in an emergency
Follow-up appointment
Removal of sutures required?
Referrals made
Dressings supplied
Patient copy of GP letter
Carbon copy of consent
Sick certificate
Has take home medication Next dose:
Information leaflet for tablets `````
Postop phone call required

41. Post operative management
Pain management
•Regular oral analgesia with paracetamol
combined with long acting non-steroidal
anti-inflammatory drugs, if not
contraindicated
•Supplementation with short acting opiates
like fentanyl

42. Postoperative management contd
Feeding
•Commencement of oral feeding is tailored based on
•The procedure and
•Patient’s tolerance
•For most abdominal surgeries
•Liquids on the night following the operation
•Light solids given on the morning of post op day 1
•Normal diet initiated on post op day 2

43. Postoperative management contd
•Emphasis on ‘OUT OF BED DAY 0’ strategy
•Structured post operative mobilization is a vital
component of fast track surgery
•Patient should be given written instructions
that include specific goals for each day
•Adequate pain control also helps in early
mobilisation
Mobilisation

44. Postoperative discharge follow-up
Patient should be able to contact a DCS team member in the
event of
• Fever
• Wound redness
• Wound discharge
A followup telephone call should be made 24 to 36hours after
the patient goes home
Patient should visit the clinic between post operative day 7
and 10 and then 1 month post surgery
Patients are given specific written instructions about the
recovery course

45. Common complications after DCS
Pulmonary embolism
Respiratory failure
Hemorrhage
Unrecognized damage to viscera
Pain
Nausea and vomiting (PONV)
Dizziness and drowsiness
Infection
Sore throat
Headache

46. Challenges of DCS 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
Poor healthcare funding

47. Conclusion
Day case surgery is now an established practice with
rates still increasing around the world due to advances
• in anaesthesia and
• surgical techniques
Day surgery is
• a high-quality,
• safe and cost-effective approach to surgical health care,
• enjoying a high rate of patient satisfaction

48. References
• IH Abdulkareem: ‘Day case surgery in Nigeria’, Nigerian Journal of
Clinical Practice, Oct-Dec 2011, Vol 14, Issue 4. DOI: 10.4103/1119-
3077.91740
• Carlo Castoro, Luigi Bert'inato, Ugo Baccaglini, Christina A.Drace
Martin McKee, ‘Day Surgery: Making it Happen’. © World Health
Organization 2007, on behalf of the European Observatory on Health
Systems and Policies
• Daniel J Quemby, Mary E Stocker, ‘Day surgery development and
practice: key factors for a successful pathway’ Continuing Education
in Anaesthesia, Critical Care & Pain | Volume 14 Number 6 2014 &
The Author [2013]. Published by Oxford University Press on behalf of
the British Journal of Anaesthesia. doi:10.1093/bjaceaccp/mkt066
• Normal S. Williams, P. Ronan O’Connell, Andrew W. McCaskie ‘Bailey
& Love Short Practice of Surgery’ 27th Edition, pg 301 -307