CARE MEDICINE SURGERY
Day Care Ent Surgery
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
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
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
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
Endoscopic surgery for pituitary adenomas, optic nerve decompression, orbital
surgery and CSF rhinorrhoea also involves staying in the hospital for a few
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
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.
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.
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.
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.
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.
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
c) submucous myomectomies
d) endometrial resection
e) endometrial ablation
2. Chorionic Villous Sampling.
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
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.
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.
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.
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
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
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
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.