• Understand the principles of ambulatory surgery and its advantages and disadvantages
• Understand the whole process of surgical operation and importance of indication of surgery, selection criteria, pre-operative assessment, peri-operative care and post operative management, discharge and follow up

• Day surg considered the best options for 50% of all Pt undergoing elective surgical procedures, though the proportion will vary between specialities.

• Reception and waiting area, consultation rooms, OT, endoscopy unit, recovery bay + seminar room (for smooth flow of Pt's + safe operation and recovery)

NOT all operations suitable

Limited by

1. Complexity of surgery
2. Possible risks and complications: eg. Tonsillectomy controversial (bleeding a potential complication); Uncontrolled DM
3. Need for post-operative care
4. Suitability for anaesthesia: major procedures need GA; Below umbilicus (hernia/ hydrocele) can use spinal anaesthesia; eg. Elderly (poor heart/ lung function) will not want to use GA (but spinal anaesthesia: cannot walk immediately afterwards, therefore cannot return home, therefore not suitable for ambulatory surgery
5. Social/ home environments: Pt needs recovery in safe environment at home (eg. Elderly living along, spouse handicapped); stairs/ lift (eg. Br lump can walk, hernia cannot)

• Ambulatory surgery = less cost for hospital
• Critical considerations

1. Safety of the approach of treatment
2. Pt acceptance: HK more likely to delay time to return to normal function; Caucasians more likely to RTW early

• Practical determinants

1. Readmission rate (< 2-3 %)
2. Postoperative complication rates (not greater than in-patient procedures)

• Cost is not the essential factor for determining potential application of day surgery (look at Pt's individually)

1. Indication for surgery? Eg. Hernia (progress, complications), Facial sebaceous cyst (cosmesis, infection, enlarging)
2. What operation/ method? Eg. Sebaceous cyst (complete excision, incision and squeeze out contents), Hernia (LA, open method, laparoscopic method)
3. Anaesthetic route? Eg. LA, GA, sedation, spinal block, combinations
4. Is the patient fit medically? Eg. Poor DM (control DM before op); COAD (GA no good)
5. Is the patient fit psycho-socially?
6. Need counselling of patient regarding peri-operative care (informed consent; expectations, complications, risks) - eg. Parotidectomy: potential risk of facial nerve palsy
7. Administrative policy also important

• Pre-operative assessment and screening for suitability of day surgery
• Joint assessment by anaesthetists, surgeons and day surgery nurses
• Medical, surgical and social / personal fitness for day surgery
• Pre-operative counselling of operation procedures, pre-operative preparation and post-operative care (eg. Counselling wrt pain - Pt perceives less pain)

1. Dx/ working diagnosis?
2. Benign/ pre-malignant/ malignant?
3. Indication for operation? (1) (Pre-) malignant (2) Symptomatic or increasing size (3) Complications (Tx/ prevent) (4) Cosmesis (size, location)
4. Types of surg (extent, alternatives)
5. Anaesthesia (GA, LA, regional)
6. Adv of surg > conservative Tx?
7. Patient willing -> surg?
8. Patient fit?
9. Surg safe as day surg?

• Avoid extreme of age.
• Pt fit + healthy (Am Soc Anesths class I and II. Patients in class III may be suitable if well controlled)
• Avoid operations where severe postoperative pain, haemorrhage or high risk of complications may arise
• Avoid op req special care post-operatively
• Exclude patients who are grossly obese (anaesthetics distributed to fat, then redistributed to circulation), poorly controlled DM or chronic resp/ CV dis
• Pt must be accompanied home

• I = normal healthy patient
• II = mild systematic disease
• III = severe systematic disease not incapacitating
• IV = incapacitating systematic disease with threat to life
• V = morbid patient

• Unfit (not ASA I, II or III)
• Previous history of anaesthesia adverse effect
• Gross obesity

• Specific problems e.g. multiple recurrent hernias
• Specific care required postoperatively
• Unsuitable size of pathology
• Operation time over 90 minutes

• Concept of day surgery unacceptable to patient
• Psychologically unsuitable
• Lives > 1-hr drive from day surgery centre
• No easy access to casualty service
• No competent relative or friend to accompany or drive patient home after operation or take care of patient at home for 24-48 hours
• No access at home to telephone, indoor toilet/ bathroom, lift service if lives in upper floors
• Note: >2/3 reasons due to social reasons

• Hernia repair
• Circumcision
• Varicose vein surgery: minor (not major resection)
• Haemorrhoidectomy: using stapler
• Fistuloctomy and minor excisions
• Excision of breast lump
• Excision of skin lesions: sebaceous cyst, fibroma
• Remove foreign bodies
• Endoscopy and colonoscopy

• Cystoscopy
• Cystoscopic ablation of tumours
• Cysto-ureteroscopic removal of stones
• Minor prostatic surgery: prostatectomy
• Trans-rectal prostate biopsy
• Vasectomy
• Hydrocoele excision
• Orchidectomy/ orchidopexy
• Testicular biopsy

• Excision of skin lesions
• Local skin flaps
• Excision of small skin tumours
• Skin grafts
• Liposuction
• Scar revision
• Minor reconstruction procedures

• Myringotomies and grommets: drainage through tympanic membrane
• Sleep endoscopy
• Other simple nasal endoscopy and excisions
• Close reduction of nasal fracture

• Dental surgery - tooth extraction
• Eye surgery - cataract surgery, simple excision
• Orthopaedics - carpal tunnel release, removal plates
• Gynaecology - laproscopy, tubal ligation
• Anaesthesiology - pain management

• Lap cholecystectomy
• Lap hernia repair
• Lap varicocele surgery
• Prostatectomy (TUPVP)
• Thoracoscopic cervical sympathetomy
• Parotidectomy / submandibulectomy?
• Thyroidectomy?
• Tonsillectomy?

• Ensure safe operation and minimise complications
• Fasting for GA/ SA/ IV sedation/ endoscopy
• Pre-op cleansing of operation site/ shaving
• Bowel preparation for lower GI operation/ endoscopy
• Adjustment of medication eg. DM, anticoagulant
• Consent/ marking of OT site
• Prophylactic ABX if indicated
• Allergy and infective status

• 0800 registration
• am operation
• pm recovery
• 1600 re-assessment
• 1700 discharge

Perioperative care depends on

1. Type of operation
2. Type of anaesthesia
3. Individual patients

Ensure safe and uncomplicated operative and anaesthesia procedures

Monitor patient's neurological state and pain response

Identify problems early by monitoring vital signs

1. Pulse rate and SaO2 by pulse oximeter
2. BP manometer
3. End tidal CO2
4. Temp
5. Urine output: Foley

Depends on type of operation and anaesthesia

GA Pt are nursed in recovery room and assessed half-hourly on the following 5 areas:

1. Vital signs
2. Pain, nausea & vomiting
3. Surgical bleeding
4. Ambulation & mental status
5. Fluid intake and output: eg. Hernia (pain stimulates reflex causing acute retention of urine)

Recovery Policy - The Toronto Western General Hospital Discharge Scoring System is adopted. A total score of 9 or above indicates fitness for discharge

• Within 20% of pre-op value (2)
• Between 20 - 40% of pre-op value (1)
• > or > 40% of pre-op value (0)

• Oriented x 3 AND gait steady (2)
• Oriented x 3 OR gait steady (1)
• Neither (0)

• Minimal (2)
• Moderate (1)
• Severe (0)

• Minimal (2)
• Moderate (1)
• Severe (0)

• Has had PO fluid AND voided (2)
• Has had PO fluid OR voided (1)
• Neither (0)

TOTAL SCORE ( )

• Surgery may be conducted under GA, regional, LA, sedation added to LA (MAC-monitored anaesthesia care)
• Depends on surg/ Pt factors

• Avoid problems of GA (eg. post-op nausea and vomiting (PONV), dizziness, sore throat and pain, aspiration or aw problem)
• Pt conscious and anxious
• Limited by type, extent and site of operations
• Infection at injection site is a contraindication
• Commonly used for simple excision of skin lesions

1. Direct infiltration
2. Field block: surrounds whole lesion

1. Loco-regional nerve block: eg. Infra/ supraorbital, penile, digital blocks
2. IV anaesthesia
3. IV sedation as adjuvant
4. Long-acting agents for post operative pain control

1. Avoid overdose: lignocaine 200mg; bupivacaine (marcaine) 150mg; lignocaine with adrenaline 500mg
2. Avoid use of adrenaline over end artery region eg. digital and penile block (adrenaline causes VC - gangrene)
3. Avoid infective foci
4. Beware of overdose, side effects and anaphylactic reaction

1. Drowsiness
2. Dizziness
3. Tinnitus
4. Numbness of tongue
5. Confusion
6. Blurring vision
7. Muscle twitching
8. Convulsion
9. LOC
10. Coma
11. Hypotension
12. Respiratory failure

13. Cardiac arrest

• Important part of post operative care
• Affect well being of the patient
• Poor pain control decreases mobility and increases complications eg. chest infection, venous thrombosis
• Adequate pain control according to pain ladder (start conservative, then move to stronger pain agents)

• Route of administration - oral, IM, IV or continuous infusion (ambulatory - mainly PO route)
• Local and regional nerve block using bupivacaine
• Regular medication / prn prescription
• Different agents have different potency and side effect

1. Simple analgesic (paracetamol, codeine,)
2. NSAIDs
3. Opioids: eg. Morphine
4. Local anaesthesia
5. Regional nerve block
6. Combination of above

• Types of suture used - absorbable or non-absorbable and suturing technique
• Local wound factors - vascularity, tension, movement, tissue trauma
• Generally

1. Head and neck 5-7 days
2. Trunk 7-9 days
3. Limbs 10-14 days

• Verbal information at pre-operative consultation, peri-operative care and post-operative enquiry
• pre-anaesthesia visit, pamphlets, telephone
• Include information on pre-operative preparation, fasting, bathing, time of arrival, post operative wound care, pain control, detection of complications, stitches removal, driving, work, sports, follow up appointment, etc.
• doctors, nurses, anaesthetists equally involved

• Infectious status eg. Hep B carrier
• DM
• Prophylactic ABX
• Patients on anticoagulants or with bleeding tendency

• Telephone follow up Day 1 and Day 3 for all GA cases and selected LA cases
• 24 hours telephone help-line
• Ensure smooth recovery of the operative procedures

Direct Access Day Surgery

• Comparison with current practice
• Do not need to see SOPD

(A process of auditing for better improvement)

• Total no. of admission
• Total no. operation
• Types of operation
• Waiting time
• Defaulted rate
• Cancellation rate
• In-patient transfer
• Re-admission rate
• Complications
• Patient appreciation/ complaint

• Less invasive procedure
• New technique
• Change technique
• Change habit to logic