Day case surgery, also known as ambulatory surgery, involves planned admission and discharge of a patient within 12 hours for a surgical procedure. It provides several benefits over traditional inpatient surgery such as shorter hospital stays, lower infection rates, and more efficient use of healthcare resources. Common procedures performed as day cases include hernia repairs, cataract removal, and tonsillectomies. Careful patient selection and optimization, as well as coordinated perioperative management involving preoperative assessment and education, regional anesthesia when possible, early mobilization and feeding, and established discharge criteria are important for success. Day case surgery allows for treatment of more patients while maintaining high quality care.

1. Day case surgery
By
Dr Olofin
Pediatric surgery unit MDH

2. outline
• Introduction
– Definition
– Other forms of ambulatory surgery
– History
•Benefits of day case surgery
• Models of cares
• Day Case Work Flow
• Common Day case procedures
• Selection Criteria
• Peri-operative management
• Pre operative assessment
• Intra operative management
• Post operative management
• Discharge
• Follow up
• Challenges in the developing
world
• Conclusion

3. Introduction
Day surgeries can be defined as the planned admission of a patient for
a specific surgical procedure and discharge within the 12-hour working
day
• Requires full sterile theater and recovery room facility
• A patient pathway extending from first contact to final discharge
• Success demands that each component of this pathway is safe,
efficient and performed in sequence

4. Intro Cont…
Other forms of ambulatory surgery
– Outpatient surgery: not admitted to a ward facility
– Procedure room surgery: surgery not requiring full sterile theater
facility
– Overnight stay/ 23-hour stay: overnight admission with early
morning discharge
– Short stay surgery: admission up to 72 hours
– Inpatient surgery: Requires more prolonged admission. Patients who
are planned as inpatients but discharged home the same day of surgery
counts as Inpatients with zero length of stay

5. History
• James Nicoll: 20th century Glaswegian surgeon. 9000 pediatrics day
case procedures. Motivated by financial benefits, concerns over
hospital acquired infections and lack of bed space
• 1951: first Hospital based day surgery unit opened in the US, UK
(1969)
• 1989: formation of British association of Day case Surgery (BADS).
• International Association of Ambulatory surgery (1995)

6. Benefits of day case surgery
• Day case surgery represents high-quality patient care with excellent
patient satisfaction
• Shorter hospital stay and early mobilization
• reduce rates of hospital-acquired infections and venous thromboembolism
• enables a higher number of patients to be treated, thereby reducing waiting
lists.
• reduces demands on healthcare resources (human, non human and financial)
• less interruption to social life of patients
• Ensures smaller patient waiting times and less risks of cancellations

7. • The release of inpatient facilities for more complex and emergency
cases.
• Fixed scheduling, reducing cancellations by patients and thus more
efficient theatre use.
• Staff reductions, as overnight staffing is usually not necessary.
• A decrease in both the time taken to perform surgical procedures and
their cost, taking advantage of advances in surgical and anaesthetic
care.
• Better use of high-cost operating room apparatus and supplies.

8. Models of cares
• Office based care
• Stand Alone day surgery facility
• Self contained integrated facility/Hospital autonomous unit
• Integrated day and Short stay surgery facilities

9. Models of Care
• Office based care
– Diagnostic and ambulatory interventions are performed in
consultation premises
– Provides readily accessible health care to patients
– Limited to procedure under local anaesthesia +/-conscious sedation

10. Stand Alone day surgery facility
– A free standing unit not geographically or
administratively part of any other health care facility
– A hospital satellite unit which is located away from the
parent hospital or within the compound
– Cases limited to procedures under LA & RA,
minor to intermediate procedures under GA

11. Self contained integrated facility/Hospital autonomous unit
– Structurally part of a hospital
but functionally separate
– Self sufficient: have own
reception, ward, theater, and
recovery areas
– Do not take emergency
admissions
– Have access to parent hospital
facility if required

12. Integrated day and Short stay surgery facilities
• The hospital OT and recovery rooms are used for both day cases and
inpatients
• More challenging day case procedures can be carried out

13. Pt allowed home to
await surgery
1-3 days before, team
member calls each pt to
access availability
Pt is reviewed by
surgeon and anaesthetist
Fit pt sent to discharge
process
Unfit pt are admitted to
the ward
Day case work flow

14. Common Day case 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

15. • TROLLEY of procedures: Recommended by the British Association Of
Day Surgery (BADS)
• Contains 50 procedures such as laparoscopic fundoplication, laser
prostatectomy, arthroscopy of knee & shoulder, thoracic
sympathectomy to be done on day case basis.

17. Selection criteria
• Medical criteria
• Social criteria
• Surgical criteria

18. Medical criteria
• Age: no upper age limit
• Comorbidity
– ASA 1&2 for stand alone units, ASA 3 for integrated facilities
– Diabetes: controlled Types 1&2 with HBA1c < 8.5%
• Should be first on list
• Morning list patients can skip morning dose of oral hypoglycemic meds or insulin
• Afternoon list patients and patients on continuous infusion are managed closely with
diabetic team
– Hypertension: <180/110mmhg

19. – Epilepsy: Well controlled patients continue routine meds in the pre
operative period
• Poorly controlled patients are reviewed with medical team.
• Social support is very important
– Obesity: not an absolute contraindication
• BMI: 40 for surface procedures, 38 for laparoscopies
• Reviewed for co-morbidities
• At risk of sleep apnea post operatively
– Anticoagulants: Patients with atrial fibrillation, hx of PTE, or on a
metal heart valve must be reviewed with a cardiologist if surgery
requires discontinuation of anticoagulation

20. Social criteria
• Consent: Patient/care giver must be willing to cooperate, able to
understand, comply and cope with post-procedural instructions
• Escort: a responsible and physically able adult
• Transport: A journey time of 1hour or less
– Comfortable transportation
• Comfortable home facilities with appropriate toilet facilities
• Communication: means of communication with hospital

21. Surgical Criteria
• Simple surgery up to 2hours.
• 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.
• Procedure must not require prolonged immobilization post operatively
• Rapid return of normal food and fluid intake possible after the procedure
• Venous thromboembolic risk assessment for prolonged procedures

22. Peri-operative care
• Pre operative assessment
• Intra operative care
– Anaesthetic technique
– Maintenance of normothermia
– Fluid management
– Minimization of Incision and Mini Invasive Surgery
• Post operative care
– Pain, PONV etc.
– Post op feeding
– Mobilization
– Drains & catheters

23. Peri-operative management
Pre-operative assessment
• To educate patients and caregivers regarding day surgery pathways
• To impart information regarding planned procedures and
postoperative care to help patients make informed decisions;
important information should be provided in writing
• To identify medical risk factors, promote health and optimize the
patient's condition

24. • Evaluation and optimization of patient’s fitness for surgery
• Should be performed early in the pathway
• Past medical history and clinical examination
• Basic health screen: BMI, Blood pressure
• Appropriate investigations: FBC, EUCR, Clotting profile, and other
specific investigations
• Best performed by specialist nursing team supported by an
anaesthetist with interest in DCS

25. • Assessment 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

26. • 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 up to 2-3hrs before surgery.
– This measure improves
• preoperative feelings of thirst, hunger, anxiety
• reduces post operative insulin resistance and
• reduces the catabolic stress response to surgery

27. 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 individualized exercise program.

28. Pre-operative fasting
• Current preoperative fasting guidelines recommend a 2 hour fasting
for clear liquids and a 6 hour fast for solids.
• Tailored to suit scheduled time for surgery

29. Patient education and consent
• 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
• A written informed consent is obtained

30. Pre operative
Instructions
Form

32. • The theater list
– Dedicated DCS list
– Mixed inpatient and DCS list
• Pre medication
– Benzodiazepins
– Antiemetics e.g. ondansetron
– Antacids and H2 antagonists
– Analgesics (NSAIDS preferred over opioids)

33. Intra operative management
• Anaesthetic techniques
– General anaesthesia
• Propofol is the IV agent of choice for induction
• For maintenance anaesthesia desflurane and sevoflurane are used as they
facilitate early recovery.
• Short or intermediate acting non depolarizing muscle relaxants are used. Eg
cisatracurium, mivacurium
• Sugamadex is a new compound which has shown to provide faster reversal of
non depolarizing muscle relaxants

34. – 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, mini dose lidocaine (10-30mg), bupivacaine (3.5-7mg) or ropivacaine
(5-10mg) spinal anaesthetic techniques are combined with potent opioid analgesic like
fentanyl (10-25mcg) or sufentanyl (5-10mcg)

35. • 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.

36. • 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

37. • 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
– aggressive post operative management of shivering and residual
hypothermia decreases incidence of wound infection, myocardial
ischeamia and protein breakdown.

38. • 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.
– Soluset for paediatric patients

39. • Minimization of incision
– The incision should be as small as possible while allowing adequate
exposure
– Laparoscopic techniques must be used whenever possible

40. Post operative management
• Postoperative feeding
• Commencement of oral feeding is tailored based on
– the procedure and
– patients tolerance.
• For most abdominal surgeries:
– liquids on the night following the operation with
– light solids given on the morning of post op day 1
– normal diet initiated on post op day 2

41. • Mobilization
• 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 mobilization.
• DRAINS and catheters impede independent mobilization.

42. Post operative management
Post-op complications
MAJOR MINOR
Pulmonary embolism Pain
Respiratory failure PONV
MI Drowsiness
Haemorrhage
• Reactionary (usually 4-6hours post op)
• Secondary (after 24hours post op)
Minor bleeds
Unrecognized damage to viscous Infection
Headache

43. Active management of PONV
• Give IVFs to rehydrate
• 10-15mls/kg over 1hr
• Give IV antiemetic e.g. cyclizine , prochlorperazine
• Review in 1hr
• If still vomiting, give a 2nd antiemetic of different type e.g. ondansetron,
dexamethasone
• Patient is hydrated and can be reassured that no further active
management is possible
• Offer choice if admission or to be discharged home.

44. Discharge criteria
• Stable vital signs for at least 1hour
• Return to base line orientation
• Ambulation without dizziness
• Minimal pain and PONV
• Minimal bleeding at the surgical site
• Tolerate oral fluids
• Has passed urine
• Responsible adult to take patient home
• Has received supply of oral analgesia, written and verbal
instructions about post op care, follow up appointment and emergency contact
number

45. (A TOTAL PADSS SCORE >/= 9
IS
CONSIDERED FIT FOR
DISCHARGE)

46. Follow up
• PATIENT SHOULD BE ABLE TO Contact the team member of the day
care surgery 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.

47. 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
• 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.

48. Conclusion
• Day case surgery is now an established practice with rates still
increasing around the world due to advances in anaesthesia and
surgical techniques
• Efforts should be made to utilize evidence based care to push the
frontlines in developing countries

49. References
• 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, Issue 6, December 2014,
Pages 256-261, https://doi.org/10.1093/bjaceaccp/mkt066
• Normal S. Williams, P. Ronan O’Connell, Andrew W. McCaskie (2018)
Bailey & Love Short Practice of Surgery 27th ed.
• MANOJ VAIDYA, Ambulatory surgery, slideshare
• Mukhtiar Ahmad, Anesthesia for Day Case Surgery, Slidshare

50. Thank you