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DAY CARE MEDICINE SURGERY

Day Care Ent Surgery

Nishit Shah
Introduction
As surgery takes every step forward in the journey toward better and newer techniques, so too must we remember to take the parallel journey of patient care.

As costs escalate, the emphasis must focus on attempting to keep things at an affordable level for the patient and yet do so without cutting corners, as far as success and safety are concerned. Also most patients would be more comfortable in the surroundings of their home than the sterile environments of a hospital. Fortunately, the ENT surgeon can offer the patient the choice of day care surgery in the majority of situations.
With Day Surgery, patients are admitted to the hospital, have their operation performed, recover from anaesthesia, and go home with their family all in the same day.

Pre-assessment
The surgery will require pre-assessment of all patients, especially those who have a history of heart problems, asthma or any other chronic diseases. The anaesthetist may be asked to assess the patient pre-operatively if required. The patient should be explained about the surgical procedure, associated risks and recovery and asked to sign consent for surgery. The patient is also asked to provide a list of the current medications, allergies, any previous hospitalizations with dates, and any other relevant information.

It is very important for the patient to call the office if he is sick during the week before surgery. A mild cold or upper respiratory infection can lead to an increased risk from anaesthesia. This includes the development of pneumonia or asthma after surgery. The surgery then is rescheduled after treating the problem. When performing ear, throat or nasal surgery, it is imperative to have preoperative control of any infection so that the congestion and bleeding are minimal. Antibiotics or decongestants if required, are given at this pre-assessment. Also, if the patient is on aspirin or any other drug which may adversely affect surgery, the patient is asked to stop the drug, if possible.

The patient is usually asked to remain fasting overnight and report to the hospital for admission in the morning. Children may be given some clear liquids containing sugar, such as apple juice or Sprite up to two hours before surgery. Breast milk may be given up to four hours before surgery.

Day care surgeries iN

ENT
Ear surgery
Most ear surgeries are done as day care cases.
Myringotomy and grommet insertion: Making an incision in the eardrum to drain middle ear fluid and putting in a ventilation tube. This is easily done under local anaesthesia without sedation in the adult patient, and the patient may be sent home within 1 hour of the operation. Children can be done with short general or with ketamine and sent home as soon as they are fully awake, and after the anaesthetist has given his okay.

Tympanoplasty: Repair of the ear drum with restoration of the middle ear hearing apparatus. This is done under local anaesthesia with sedation and the patient may be sent home when fully alert.

Mastoidectomy: Removal of disease (usually cholesteatoma) from the mastoid and middle ear, with or without reconstruction of tympanic membrane and hearing apparatus. Can usually be done under local anaesthesia with sedation. If the patient is apprehensive, general anaesthesia may be required as the surgery may sometimes stretch to 3 hours or more. These patients can also be sent home the same day.

The patient may occasionally have vertigo after mastoidectomy or ossiculoplasty and should be informed before hand. In this case the patient may have to stay in the hospital for an extra day. In the normal course, they will be asked to follow up after 3 days for routine dressing and 7 days for suture removal. In case of pain, vertigo or bleeding they will see the surgeon as soon as possible.

Stapedectomy: Surgery for restoration of hearing in otosclerosis. This is usually done with local anaesthesia and sedation. These patients can sometimes have post-operative vertigo and even vomiting. In the event of vertigo, or complicated surgery, the patient should be kept overnight, or till he is better. Most patients can however go home the same day, provided travel is short and smooth. Air travel is not advisable in the immediate post operative period.

Tympanoplasty and stapedectomy are only occasionally done in children. Mastoidectomy is always done with general anaesthesia and the children are usually asked to stay overnight.

Nasal Surgery
Most septal and sinus surgery can be done under local anaesthesia with sedation. However, both involve nasal packing. Whilst patients can be sent home with nasal packs, some surgeons (including myself) don’t feel comfortable doing this. If the patient were to have some bleeding at home, then neither he nor the doctor would know if it were significant bleeding unless seen personally, which means the surgeon would have to rush to the patient’s home in the middle of a busy day maybe to find only insignificant oozing! However, if the patient were to be admitted he would be attended to immediately by the resident doctor.

On the other hand, most patients do not bleed and tend to be more comfortable at home and could be called to the clinic after 24-48 hours for pack removal.

Endoscopic Dacryocystorhinostomy (DCR) can be done easily under local anaesthesia and sedation and the patient sent home after pack removal in the evening, provided there is no bleeding.

Endoscopic sinus surgery involving extensive polyposis or disease and in the posterior sinuses is done under general anaesthesia and these patients will usually stay in hospital as there may be bleeding associated with major sinus surgery.
Endoscopic surgery for pituitary adenomas, optic nerve decompression, orbital surgery and CSF rhinorrhoea also involves staying in the hospital for a few days.

Patients who have epistaxis (without any major causative pathology) are excellent candidates for day care endoscopic surgery. Earlier these patients would be packed for 48 hours and the packs removed with frequent rebleeding. Now, with the endoscope, the bleeding point can be identified and cauterized and the patient sent to the room without packing and fear of bleeding, to be discharged after a few hours of observation.

Throat and laryngeal surgery
Tonsillectomy and adenoidectomy have always been done as day care procedures. The patients are sent home in the evening after checking the fauces for clots or bleeding.

Oral biopsies, buccal leucoplakia excision and other such minor surgeries are also excellent day care situations.
Even most rigid endoscopies, such as direct laryngoscopy, microlaryngoscopy and oesophagoscopy, done under general anaesthesia lend themselves to being day care cases. These are usually short procedures for diagnosis, biopsy, and therapeutic excision of small lesions or foreign body removal and do not entail much bleeding or major surgery.
Rigid bronchoscopy or surgery for tumours would require more hospital stay.

Post-operative
After surgery, the patient is kept in the recovery room until the vital signs (blood pressure, heart rate, and temperature) are stable. The surgeon and anaesthetist will see the patient before shifting to the room. Discharge occurs after the patient is alert, can hold fluids without vomiting and has passed urine.

Conclusion
In conclusion it would be fair to say that most ENT surgery can be done as day care surgery, some would require 1-2 days hospital stay and only very few would require longer stay.

Day Care Surgeries in Obstetrics and Gynaecology
Nitin Pai-dhungat*, PB Pai-dhungat**
Day care surgery is followed in many disciplines today. But, it would be worthwhile to mention that the faculty in which day care was initially followed on a large scale even in earlier times is obstetrics and gynaecology.

INTRODUCTION
By definition, a day care surgery is an operation / procedure, excluding an office or outpatient operation / procedure, where the patient would normally be discharged on the same day.

Prior to the advent of endoscopy, dilatation and currettage and Rubin’s insufflation test were done as day cases. These were performed for incomplete abortion and infertility mainly.

Before laparoscopic tubal ligation came into vogue, open tubal ligation was performed as a day case surgery. Even today in the moffusil areas, open tubal ligation is performed as a day care surgery.

Laparoscopic tubal ligation is a procedure of minutes. Dr PV Mehta of Mumbai city has the distinction of performing the largest number of Lap TL’s in the world. Laparoscopy also superseded Rubin’s insufflation test as a diagnostic procedure.
In the early 1980s, therapeutic laparoscopy came into vogue. The main aim of minimal invasive surgery was to reduce morbidity. But, definitely one of the advantages: is early discharge from the hospital.

PROCEDURES
A list of the indications or procedures that may be performed as day care surgery will be mentioned here. But, please note that this is not an exhaustive list.

GYNAECOLOGICAL INDICATIONS
1. Dilatation and curettage
2. Cervical biopsy
3. Diagnostic Hysteroscopy
4. Diagnostic Laparoscopy
5. Therapeutic Laparoscopy which includes:
a) Tubal cannulation
b) Ovarian drilling
c) Myomectomies for small fibroids
d) Endometriosis ablation
e) Simple Oophorectomies
f) Tuboplasty, fimbrioplasty
6. Therapeutic Hysteroscopy:
a) Septum resection
b) Polypectomies
c) submucous myomectomies
d) endometrial resection
e) endometrial ablation

OBSTETRIC INDICATIONS
1. MTPs
2. Chorionic Villous Sampling.
3. Amniocentesis.
4. Embryo reductions.
5. External Cephalic Version.

Dilatation and currettage along with cervical biopsy for diagnoses of endometrial and cervical cancer have been performed since time immemorial. Blind D and C is no longer advocated and hysteroscopic guided biopsies are advised.
Hysteroscopy also forms an important part of pre -IVF evaluation. Hysteroscopy is not only performed as a day care surgery but also as an office procedure without anaesthesia and dilatation. Therapeutic hysteroscopies in the form of polypectomies, septum resection or fibroid resection are also done as day care procedures. Endometrial ablation techniques to induce amenorrhoea offer the advantage of only a days admission.

However, the results are not as good as initially expected. They also tend to be performed more often in cases with high risk of anaesthesia and this tends to longer admission periods.

In 1972, with the relaxation of the MTP act, suction and evacuation has become a very common day care procedure.
Menstrual regulation, and its newer form, the manual aspiration are also used for termination of pregnancy and performed as day care procedures even in poorly equipped set ups.

Combining MTP and TL has helped the family planning programme significantly. Other than MTP, obstetrics offers few indications for day care procedures.

Chorionic villous sampling and amniocentesis can be done, ideally with the help of ultrasonography.
MacDonald’s or Shirodkar’s stitch may be performed as day care only in exceptional circumstances.
Laparoscopic assisted vaginal hysterectomy was initially propagated as a day care procedure; however, it’s not yet been accepted as a standard procedure.

Quite a few articles in this issue would delve into the advantages and disadvantages of day care surgery. Hence, we will enumerate only some of the advantages and disadvantages. This is not an exhaustive list.

Advantages
1) Reduces morbidity for the patient.
2) Negligible disturbance of family life.
3) No crowding of the hospital beds.
4) Low cost / economical benefits.
5) Smaller set ups are equally good.

Disadvantages
1) No complicated cases can be done.
2) Patient may be lost to follow up.
3) Effective emergency care should be available in case of complications.
4) Late complications may be easily missed.

DISCUSSION
Case Selection:
1) Fit patients.
2) Easy cases.
3) Low risk of complications.
4) Patient must understand the need for pre-op. and post op follow up.
Criterion For A Day Care Unit:
1) Well equipped
2) Trained staff
3) Competent doctors
4) Close to or part of at least a referral hospital
5) Registered hospital

Case selection for day care surgery is one of the most important points. To give an example, an interval laparoscopic tubal ligation in a healthy 28 year old woman is an ideal day care surgery. But, if it is an asthmatic 28 year old with previous lower abdominal surgeries, she would not be suitable for day care surgery.

The anaesthetic fitness of the patient must be confirmed prior to surgery. Ideally, there should be a pre-surgical check up in the form of a visit to the anaesthetist.

Investigations, though minimum, should not be omitted. The whole process with regards to booking and anaesthetic check up may even take upto a week or more.

Written consent of the patient prior to surgery is as important as in routine cases. The development of booklets and leaflets which can be given to the patients explaining the nature of the procedure, can help the patient’s confidence
The day care centre must be suitably equipped. It would be a grave injustice to the patients if the centre was minimally equipped only because day surgeries are being performed.

Emergency drugs and equipment should form an integral part of any such unit. Trained personnel, present at most times would go a long way in managing any complications.

A postoperative visit is essential to discuss the result of a diagnostic laparoscopy.
Similarly, in case of MTP, it is important to discuss contraception.

Before discharge, all patients must be assessed, and in case of suspected complications, it is far safer to keep the patients for a day more. Even general hospitals have practised day care surgery since long.

A recent decision of the government that all Tubal Ligation patients be admitted for 24 Hours, may need to be reviewed. It may be changed so that only difficult T. L.’s or where complications are expected should be admitted for 24 hours.

CONCLUSION
The field of obstetrics and gynaecology should take the lead in development of guidelines for day care surgery. The advantages of day care surgery clearly offset the disadvantages in properly screened cases.



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