Discuss Day Case

Surgery
Dr Nwosu C
Dept of Surgery
JUTH

Outline

Introduction
Design of Day Case Surgery
Advantages & Disadvantages
Patient selection
Operation selection/Day case procedures
Contraindications
Pre-op preparation
Anaesthesia & Post Anaesthesia Recovery
Post op care
Discharge criteria/ Follow up
Complications
Day case surgery in the tropics
Day surgery in Children
Future trends/ conclusion

Introduction
Definition
History
James Nicoll Scottish surgeon(1909)
Ralph Waters USA (1912)
Eric Farquharson (1951)
1960 Hospital based DSUs
1969 Walter Reed American Surgeon
1970s -DSUs in UK hospitals

Design of Day Case Surgery

1.
2.
3.

3 main forms
Day Surgery Unit
Day Case Ward
General ward

1.Day Surgery Unit

Self contained dedicated DS facility

Highly organized and efficient
Same high standards
Adjacent parking space
Trained, experienced staff

1.Day Surgery Unit

Teamwork, liaison with community services

Management, audit and Quality control
The reception area
Day surgery ward
Anaesthetic room & operating theatres
Recovery area

2.Day case ward

3.General ward

Advantages
Patients
-minimal time away from home
-sed disruption of normal activities
-ced waiting period
-lower complication rate
-cost effective
2.
Surgeons
-better scheduling of cases
-sed turnover of cases
-ced delay between cases
-greater fulfillment
1.

Advantages
3.

Hospital management
-greater efficiency
-in patient bed available
-closed at nights and weekends

Disadvantages

Increased burden for relatives

Reduced training opportunity
Initial setting up cost

Patient selection
1.

2.

3.

Physical fitness
-Age < 70yrs
-ASA I or II
-Generally fit and ambulant
-BMI <30
Social factors
-responsible adult
-live within an hours drive
-conducive home circumstances
Associated medical conditions/ drug history

Operation selection/ Day Case

procedure

Criteria
-minor cases
-low risk of post-op complications
-duration
-pain control
-reasonably ambulant afterwards
-not require blood, IVF or IV drugs
-drains, catheter, skin closure

Day Case Procedures

Diagnostic
A.
General Surgery
-endoscopy
-tissue biopsies
-radiographic
-laparoscopic
B.
Urology
-endoscopy
-tissue biopsies
C.
Orthopaedic
-biopsies -open or arthroscopic
D.
Plastic surgery
-biopsy of skin lesions

Day case procedures

Therapeutic
A.
General surgery
-endoscopic
-open procedures
-radiological
-laparascopic
B.
Urology
-intravesical instillations
-urethral stricture
-endoscopy
-open procedures

Day case procedures

-laparascopic
C.
Orthopaedics
-arthroscopy
-removal of implants
-MUA
D.
Plastic surgery
-excision of skin lesions
-revision of flaps/ scars
-insertion and distention of tissue expanders
-cosmetic surgeries

Contraindications

Medical
Psychological
Social

Pre op preparation

1.
2.
3.
4.
5.
6.
7.
8.

Seen at pre admission clinic

Explain nature of problem and intended surgery
Protocol of the day unit
Fasting; accompanying person
Transport ; informed consent
Relevant investigations
Post op restrictions
Staggered arrival
Check site and investigations

Anaesthesia and post anaesthetic

recovery

Principles of anaesthesia same

Problem free recovery
Experienced anaesthetist
LA encouraged
High quality induction, notice of recovery for GA
LA
GA
3 stages of recovery from GA
Recovery room
Ward

Post op Management

Fundamentally different
Meticulously planned
Duration
Usual problems of management
Post op visit before discharge

Discharge Criteria

a)
b)
c)
d)
e)
f)
g)

Criteria
No complications
Stage 2 recovery
Tolerate fluids and pass urine
Understand post op restrictions
Responsible adult
Discharge summaries
Contact

Follow up

A.
B.
C.

Post op instructions
Drive or operate machinery
Important decisions/ signing documents
SOPD

Complications

a.
b.
c.
d.

1.
2.
3.
4.

Incidence of major complications -0.0007%

Minor complications
Early
Pain
N&V
Dizziness and drowsiness
Minor bleeding
Late
Delayed discharge <2-3%
Readmission 4%
Sepsis
Sore throat, headache

Day case surgery in the Tropics

Early stages
General ward setting
Poorly organised
Poor follow up and cannot be assessed
Severe constraints
Lack of political will/ vision
Cancellations and reasons
Day surgery in JUTH

Day surgery for children

50% of surgical procedures in children

Ideal for children with psychological benefits
Careful planning with trained staff
Childrens DSU or children only days
Pre admission visits
Children friendly surroundings
Duration of anaesthesia
Separate rooms with special facilities

Future trends

Scope expected to expand

More invasive procedures on less fit patients

Conclusion

References

Al Fallouji M A R- Post graduate surgery

Badoe et al Principles and practice of surgery
Russel R C G et al- Short practice of Surgery
www.surgical-tutor.org.uk
www.gpnotebook.co.uk
Dakum et al Cancellations of Urological day
care surgeries