CARE MEDICINE SURGERY
Day Care Surgery An Approach to New Millennium
In 1912, the Swedish internist,
Jacobeus, was the first to write about laparoscopy. He used a special endoscope
developed for him by the Wolf Company in Germany. In his book about laparoscopy
and thoracoscopy, he mentioned the possibility of also looking into the joints.
As far as we know, he never did.
The father of Swiss surgeon, Eugen Bircher, acquired a Jacobeus laparoscope
at about the same time, and Eugen Bircher tried it in the cadaver knees around
1913 to 1914. Eugen Bircher was also the first to publish about arthroscopy
in living patients in 1921. It had earlier been believed that the Japanese researcher,
Takagi, in 1918 was the first to inspect a knee through a cystoscope. Eugen
Bircher must be given credit for having performed the first-known arthroscopy.
In the last 25 years, there has been enormous development of operative arthroscopy.
Watanabe in Japan should be credited with performing the first operative arthroscopy
in 1957 and for developing the No. 21 arthroscope. Had not the British physicist,
Hopkins, invented the rod lens and had Karl Storz in Tuttlingen, Germany, not
been smart enough to realize how revolutionary these optics were, operative
arthroscopy would never have developed the way it is. John McGinty of USA introduced
the use of television into arthroscopy.
Arthroscopy and arthroscopic surgery are among the most rapidly growing techniques
developed in the twentieth century. As a technique, arthroscopy is continuing
to expand at a rapid rate. During the 1970s the entire emphasis was on the knee.
It was in this joint that basic surgical skills were honed; the use of television
was developed, and operating from a television monitor, rather than under direct
vision, was learned. In the knee, basic procedures were learned: joint inspection,
removal of loose bodies, menisectomy meniscal repair, synovectomy, lateral release,
abrasion arthroplasty, treatment of osteochondritis dessicans, and management
of some fractures. As we moved into the 1980s, these techniques were applied
first to the shoulder and then to other joints. Now there is no joint in the
body that has not been invaded by arthroscope. Not only are the new procedures
being developed, but also techniques with new instrumentation are constantly
changing. We are seeing new and different power tools, new and updated video
equipment for both viewing and recording, and introduction and refining of laser
technology applied to arthroscopy.
During the last three decades, the evolution of arthroscopy has been mercurial.
This progress has led us to the threshold of Day Care Arthroscopic Surgery (Office
arthroscopy). The first office arthroscopy was performed in December 1989, when
a small flap tear of the posterior horn of medial meniscus was removed using
basket forceps. Day care arthroscopic surgery is the demand of the day and could
be performed for any of the problem of most of the joints of the body.
Day Care (Office) operator, must have room to accommodate video equipment, recording
equipment, monitoring equipment, a crash cart with cardiopulmonary resuscitation
equipment, an operating room table with leg holder, an autoclave, a Cidex basin,
nitrogen and oxygen tanks, and suction equipment. All arthroscopic instruments
and good tourniquet is must. Patient can walk into the operating room from office
examination table and can be discharged from there as well.
Basic minimal blood investigations are required.
For diagnostic arthroscopy: local anaesthesia, may be a little sedation, is
the only thing required. Patient may need short general anaesthesia, especially
of shoulder procedure and knee intervention. One shot of intra-operative antibiotics
is usually used. Patients are discharged with compression dressings, which is
changed on second postoperative day. Pain management is simple. For routine
procedure of knee and shoulder usually local anaesthetic agent is injected into
the joint, which gives good relief and if needed NSAID could be given as per
requirement. For major procedures pain is taken care by pain management team
headed by anaesthesiologist.
Gradual physiotherapy and rehabilitation programme is used as per individual
patient. Physiotherapy programme is to be followed rigidly during postoperative
period. The entire success of these procedures depends on good rehabilitation.
Depending on the nature of procedure, a patient returns to the office in two
to three weeks time. The emotional maturity and stability of the patient is
an important consideration when deciding whether the procedure should be performed
in the office or in the hospital. Preventing complication in the office environment
is of paramount importance and can, in most incidents, be directly controlled
by the surgeon and his team. Record of office arthroscopy should be in detail,
similar to those kept in the hospital. Documentation of every arthroscopic procedure
performed, regardless of its complexity or simplicity is of paramount importance.
Computerized management of images, videotaping and compact disc [CD] recording
are good tools.
Basically, most of the joint can be looked into through arthroscope but this
is commonly done for knee and shoulder in more than 95 times. Surgeons should
perfect basic technique and any advances must be updated. In the knee, apart
from routine diagnostic procedure, treating meniscal and chondral injuries,
patellar disorders, synovial biopsy and synovectomy, adhesiolysis, and other
many basic procedures are performed as day care surgery. Cruciate reconstruction
and any other arthroscopic procedure done along with corrective bony surgery
needs more than a day stay in the hospital. In shoulder all kind of procedures
are performed as a day care surgery.
As arthroscopy has grown rapidly in geometric proportions with increasing demands
of patients expecting decreased morbidity, out patient procedure, more speedy
return to work and recreation, media response to use these techniques in sports
medicine was an accelerating factor in growth. Instruments to do specific tasks
are more advanced; arthroscopy has grown out of the hospital into the surgeon’s
office (Day Care); methods of documentations are easier; and the orthopaedic
learning centre has realized the need to enhance education.
When doing this, three caveats must be remembered by a surgeon to be an arthroscopic
First, a learning curve to all these techniques must be mastered by the surgeon
before using them as treatment methods on his patients.
Second, as these procedural techniques develop, their results must be seriously
compared with those of other methods before adopting them. It is not advisable
for practising surgeon to adopt a new procedure before its results have been
established to be comparatively reliable and its efficacy has been proven by
one or a group of surgeons who have performed a large number of arthroscopic
Finally, we are in an era when the medical profession is scrutinized under a
magnifying glass by the public, the media and the for-profit health care providers.
Cost containment has become the by-word for health care. Before undertaking
new expensive procedures with expensive instrumentation, we must be able to
justify the additional expense. Therefore, we must be sure that as a whole,
our efforts result in saving and not in an increase of health care costs.
Office operative arthroscopy is obviously an efficient method of performing
arthroscopic surgery for patient and surgeon. The cost saving of the third party
payer and the patient are quite significant when compared to the traditional
arthroscopic environment such as the hospital operating room and ambulatory
surgery centre operating room. The advent of arthroscopic technique made rehabilitation
easier and at least early in the course of recovery, because of a resultant
decrease in postoperative pain and morbidity of adjacent tissues.
Botulin Toxin-in Day Care Plastic Surgery
Viraj S Tambwekar*, Suresh R Tambwekar**, Kumkum Khadalia***, Rustom P Ginwala+
In recent years, Botulin toxin has been a topic of fervent research, and as
with all great discoveries, its use to enhance facial features was discovered
more by accident than by intention. Since then, it has gained in popularity
and indication. This article gives a brief overview of the clinical application
of Botulin toxin in the practise of a plastic surgeon.
Botulin toxin is a neurotoxin, produced by an obligate bacterium, Clostridium
botulinum. Botulinum toxin type-A, is a very potent exotoxin and has been used
clinically in neuromuscular diseases due to its high potency. It produces its
effect by preventing the release of acetylcholine from the pre-synaptic neuron
of striated muscles. Simply put-it relaxes the concerned muscle completely,
but temporarily, thus abolishing wrinkles / lines that are seen on the skin
as a result of the contraction of the muscle.
This principle has been carried further: to use Botulin toxin (BTX-A) to reduce
the size and secretions of glands as well.
The use of Botulinum toxin has become one of the most commonly performed office-based
procedures in plastic surgery clinics in recent times.
Common indications for the use of this drug are forehead and glabellar frown
lines, baggy eyelids, crow’s feet around the eyes, peri-oral frown lines,
nasolabial frown lines, dorsal nasal, mental and submental frown lines, wrinkles
in the neck, masseter hypertrophy, hyperadenitis suppuritava, hyperhidrosis
(with or without osmidrosis) of the axilla, palms and feet.
It is also used to enhance and produce specific features in facial expression
such as the shape of the eyebrows.
It is beyond the purview of this article to describe in detail the method of
using this drug in all of the above indications; however, it is important to
understand the basic principles that need to be followed in order to gain optimum
advantage from its use.
A thorough clinical examination is a must to decide the indication (e.g. botulin
toxin is contraindicated for baggy eyelids if the snap test is negative).
In all of the above cases, it is of paramount importance to be very familiar
with the detailed anatomy of the region, the action of the muscle/s in the region
and their nerve supply (to prevent complications such as drooping of eyebrows).
BTX-A should always be diluted before use (4 ml. is a good dilution), however,
it should be remembered that increasing the volume of diluted toxin will increase
its spread in the muscle and may result in unwanted side effects such as ptosis.
More often than not, to achieve optimum results, this drug is used as an adjuvant
to surgical therapy or concomitantly with biological filler substances.
The effect of BTX-A is seen in a couple of days and is transient. The effect
typically wears off in 6-8 months time and varies from case to case. However,
this procedure is gaining in popularity with people who want a quick and cheap
solution to enhancing their appearance for a specific cause, such as, a marriage
or a modelling assignment. When I say cheap, I am comparing cost to that involved
with a surgical procedure, such as, a blepharoplasty or a face-lift or brow
Patients may require a touch up if the desired result is not obtained with the
first injection, especially if a low dose has been used initially to “err
on the side of safety.”
Side effects if any are minimal and transient, with the exception of ptosis.
The most common are pain, minor local swelling, ecchymosis, headache, nausea,
and a small area of transitory numbness.
One patient had a vasovagal attack; however that was attributed to the fact
that he was extremely anxious and was fasting as well, thus making it difficult
to rule out hypoglycaemia as the cause of giddiness, profuse sweating and a
drop in his blood pressure.
Dilution of the toxin is very important and has to be done with extreme gentleness
as any vigorous movements bring down the potency of the drug.
The area to be injected should be free of any inflammation (pimples, etc.),
or any kind of skin lesion.
It is necessary to inject a small amount of the drug in specific areas and then,
to spread it around gently with even pressure, to achieve good results.
Most importantly, adequate training is necessary before commencing practice,
as this is not “just another injection”.
The undiluted drug should be stored in a freezer and once it has been diluted,
on the shelf of the fridge door. It can be stored for between eight and ten
days in such a fashion. (In a personal communication with Dr. Woffles Wu, who
has been using this drug for quite a while now, and is one of the foremost plastic
surgeons using it, we were made to understand that the reconstituted drug may
be used for up to two weeks, with a marginal decrease in its potency).
There are many companies worldwide that manufacture this drug, and it is marketed
under various trade names. It is important to choose a company whose drug potency
and purity can be relied on and not necessarily the cheapest available.
Yes, botulin toxin has arrived and the results achieved are akin to a miracle
of sorts. We must remember that the goal of treatment is to make the face appear
more youthful and fresh, as opposed to mask like, which might be the case if
the treating plastic surgeon is too enthusiastic and aggressive.
Great maturity is to be exercised while planning the procedure and the patient
properly counselled to avoid dissatisfaction.
1. Christos Naoum, Dimitra Dasiou - Plakida. Dermal Filler Materials and Botulin
Toxin. International Journal of Dermatology 2001; 40 : 609-621.
2. K. Pavithran. Botulinum Toxin in Dermatology. What’s New? In Dermatology,
STDs and Leprosy. 2003; 34 : 2-8.
3. Alan Matarasso, Olivia H. Z. Hutchinson. Evaluating Rejuvenation of the Forehead
and Brow: An Algorithm for Selecting the Appropriate Technique. 2000; 106 (3)
4. Steven Silberstein, Ninan Mathew, Joel Saper, Stephen Jenkins, for BOTOX
Migraine Clinical Research Group. Headache 2000; 40 : 445-450.
5. Alister Carruthers, Ki Young Ahn, Mee Young Park, Sung Hai Park. The Advanced
use of BOTOX in the Face and Neck, presented at Seoul, Korea. 9/12/01.
Daycare Coronary Angioplasty
BK Goyal, Ramesh Kawar, BC Kalmath, Anil Sharma
Twenty-five years have passed since the beginning of clinical interventional
cardiology, the first human coronary angioplasty was procedure performed by
Andreas Gruentzig on 16th September 1977, at Zurich. Percutaneous transluminal
coronary angioplasty (PTCA), usually simply called angioplasty, involves opening
the blocked coronary artery. Before the advent of coronary angioplasty, CABG
(coronary artery bypass surgery) was the only hope for patients with coronary
Indications for coronary angioplasty have been dramatically changed during the
last 25 years. Initially coronary angioplasties were feasible in limited number
of cases with discrete block in one vessel, with good pumping of heart, CABG
for the rest. Presently, most of the blocks can be removed with angioplasty
including complex lesions like totally occluded artery, multiple blocks in multiple
vessels, post CABG grafts, and acute myocardial infarction (heart attack).
Day Care procedure
Plain balloon angioplasty has limitations, the risk of acute closure of artery,
need for urgent CABG and re-stenosis rate up to 50%. To combat these complications,
Puel and Ulrich Sigwart used coronary stents first time in 1986. Stent is a
slotted tube or ring like structure, made up of stainless steel or nitinol and
it acts as a scaffold. Presently the restenosis rate of stents (non drug eluting)
is around 15%. Radiation therapy has been used to reduce the restenosis rate.
Recently developed drug eluting stents are claiming nearly 0% restenosis. Hopefully
this may bypass the bypass surgery (CABG).
During coronary angiography and angioplasty the patient remains fully conscious.
It is done under local anaesthesia given at groin or hand, unlike bypass surgery,
which requires general anaesthesia. A small tube (sheath) is inserted in the
femoral artery (groin) or radial artery (hand). Through this sheath, long tube
(catheter) of about 2 mm diameter is passed and kept at the mouth of the coronary
artery. Coronary arteries are visualized by injecting dye through these catheters.
For coronary angioplasty thin wire is passed in the coronary artery via the
catheter. The deflated balloon is passed over the wire and inflated at the site
of coronary artery block to compress the plaque against the wall of the artery.
In the same way coronary stent is deployed at the site of block to keep the
artery open afterwards.
Unlike bypass surgery (CABG), which requires two weeks hospitalization and six
weeks for full recovery with significant loss of manpower, in angioplasty most
of the patients can be discharged from hospital same day (transradial) or next
day (transfemoral) to resume full duty with no scar. In angiography patient
can be discharged either in 2 hrs. (transradial) or in 6 hrs. (transfemoral).
The femoral artery, the traditional entry site, is the most appealing approach
for coronary angioplasty, because of ease of arterial cannulation and catheter
manipulation. However, there are several important limitations associated with
this entry site. The femoral artery usually runs deep under the skin, especially
in obese patients, close to the femoral vein and nerve. Following removal of
the arterial sheath, after angioplasty, bleeding complications are difficult
to prevent, despite careful haemostasis techniques and prolonged immobilization
of the patient.
On the contrary, the radial artery is a potentially safer entry site for several
reasons. The superficial course of this artery facilitates haemostasis, by simple
application of a pressure bandage over the puncture site. Important bleeding
is immediately noticed by the patient, who can at least temporarily address
this problem by himself. This is one of the reasons that blood loss is usually
minimal. Since the median nerve is well separated from the artery, this structure
is usually not damaged during puncturing or during bleeding. The absence of
major veins makes the incidence of arteriovenous fistula rare.
Lucien Campeau, pioneered this transradial technique for diagnostic coronary
studies. Kiemeneij performed the first coronary angioplasty in 1992 by transradial
However, this transradial coronary angioplasty technique appeared to be technically
more demanding compared to the traditional femoral technique, since smaller
guiding catheters have to be used. In addition, these catheters are approaching
the coronary arteries from the right side instead of left side making adequate
coronary cannulation a greater challenge. Downsized angioplasty equipments have
to be selected, requiring more delicate handling.
The price to pay for this safe and elegant technique is a new learning curve.
The reward of this effort will be apparent after the procedure, since no manpower
is required to obtain haemostasis and since bleeding complications are very
One of the most striking advantages is the free and immediate ambulation of
the patients, which is greatly appreciated in most instances. Free mobilization,
without additional risk for bleeding, opens the way to outpatient or daycare
coronary angioplasty, reducing costs and increasing efficiency of coronary angioplasty
and patient comfort. Waiting lists can be shortened, by increased turnover on
the cardiology ward.
Lately, we are performing angiographies and angioplasties through radial artery
regularly at Bombay Hospital, which avoids a lot of discomfort to the patient,
as he is fully mobile after the procedure, and can be discharged the same day.