Outpatient and Ambulatory Surgery. Surgeon. Dr. David T. Y. Lam. Specialist in General Surgery

Transcription

1 Outpatient and Ambulatory Surgery Dr. David T. Y. Lam Specialist in General Surgery

2 What is Outpatient Surgery? Historically means Minor Surgery Lumps and bumps Local Anesthesia

3 What is Outpatient Surgery? Synonym of Office Procedure Where compromise of aseptic technique can be safe Minimal instrument Low risk procedures

4 What is Outpatient Surgery? What can be done? Lipoma, Epidermal cyst Naevus Warts In-growing toe nail Small, superficial abscess Banding of hemorrhoids...

5 What is Outpatient Surgery? Stretching the limit... Perianal abscess Ischiorectal fossa abscess Back lipoma Circumcision Perianal skin tag excision Outpatient surgery is limited service

6 Can we do more? Can we give IV sedation? Adequate monitoring Antidote: Flumazenil, Naxolone Emergency airway equipment Oxygen & suction IVF YES, in a well equipped (accredited) center with necessary expertise

7 Traditional Places of Surgery Outpatient Surgery Hospital Based Surgery

8 Hospital Based Surgery Traditional place of surgery Do almost anything Hardware & Setup Equipment Personnel

9 Hospital Based Surgery Hardware & Setup Operating Suite: OR, Recovery area Pre-anesthesia room Scrubbing and gowning area Nurses station TSSU Supporting Units ICU, HDU, Specialty wards

10 Hospital Based Surgery Hardware & Setup Equipment Operating Suite TSSU Supporting Units Gases, Vacuum, Lightings, Air filter Anesthetic trolley X rays Special instruments: MAS, CP Bypass

11 Hospital Based Surgery Hardware & Setup Equipment Personnel Operating Suite TSSU Supporting Units Fixtures Anesthetic trolley X rays Special instruments Anesthetists s Nurses OR Assistants

12 Hospital Based Surgery Magnitude of surgery Risk No limit No limit Intensity of Post-operative care No limit Requires a hospital to support!

13 Surgery Types High Risk Hospital Hospital Simple need for IV sedation, GA / SA Outpatient Surgery Ambulatory Surgery Complex Low Risk

14 Ambulatory Surgery Magnitude of surgery Risk intermediate to major low Intrinsic risk of surgery Patient factor Intensity of post-operative care Limited to single day No intubation or ventilation Patient able to walk and eat

15 Ambulatory Surgery Hardware & Setup Equipment Personnel Operating Suite TSSU Supporting Units Fixtures Anesthetic trolley X rays Special instruments Anesthetists s Nurses OR Assistants

16 Ambulatory Surgery: model Patient Enters Assessment Waiting Area Ward Home Assessment OT Recovery

17 Ambulatory Surgery Center Reception Nurse assessment Anesthetist assessment assessment Waiting Area Home like & cozy Standard Operating Suite Recovery Area Equipped with Oxygen & Monitoring systems Stretchers and chairs Escape Route In-patient care facility

18 Ambulatory Surgery Surgery Type Anesthesia Type Traditional Surgery Hernia repair Hemorrhoidectomy Circumcision Plastic Surgery Liposuction Minimal Access Surgery Laparoscopic hernia repair Laparoscopic cholecystectomy General Anesthesia Spinal Anesthesia Epidural Anesthesia Regional Block Local Anesthesia

19 Ambulatory Surgery: model Patient Enters Assessment Waiting Area Ward Home Assessment OT Recovery

20 Ambulatory Surgery: model Patient Selection by Protocol based Agreed with Anesthetist and Nurses Pre-operative Anesthesia assessment Well before day of surgery Necessary investigations (blood, XR, ECG) Pre-operative Tour Familiarize patient with Ambulatory Surgery Center Allay patient anxiety

21 Ambulatory Surgery: model Post-operative Reassurances Telephone calls by nurses Hotline for patients (preferably 24 hours) Emergency access to hospital Early follow up assessment Clear instructions on wound and dressing care Adequate analgesics

22 Ambulatory Surgery: model Patient Selection Checklist for Hemorrhoidectomy Patient < 70 year old Ambulatory and understands instructions ASA 1 or 2 No pre-existing DM, IHD, COAD No BPH or prostatism No history of complicated anesthesia No clinical evidence of sepsis Willing to go home the same day after surgery Does not need to climb stairs Adequate social and home support

23 Ambulatory Hemorrhoidectomy Primary aim: Feasibility of ambulatory hemorrhoidectomy Secondary aim: Cost effectiveness of ambulatory hemorrhoidectoy Study Design: Case Controlled Study Lam et al, ANZ J Surg, 2001

24 Ambulatory Hemorrhoidectomy Material and method Results 30 Ambulatory cases (A) vs. 15 In-patients (I) Ambulatory cases discharge rate: 87% Unplanned readmission: A=4, I=3 (p>0.05) Average hospital stay: A=1 day, I=4 days Conclusion Ambulatory hemorrhoidectomy is feasible, safe and shortens hospital stay

25 Ambulatory Surgery Cost Benefits: Ambulatory Surgery Center: Hardware and Setup: No ICU required, less ward support Equipment: Less specialized equipment Personnel: Nurses need no night shifts Patients: Less overnight stays Insurance: Lower overall claims

26 Ambulatory Surgery (5C=2PS) Patient Safety Competent Anesthetist Nurses Cautious Patient selection Surgical decision Patient Satisfaction Comfort Waiting area Recovery area Convenient Cost-containment