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DAY CARE MEDICINE SURGERY

Day Care Surgery : A General Surgeon's Perspective
T Naresh Row, MM Begani, Niranjan Agarwal
Day Care or Ambulatory surgery is rapidly developing in our country. A regular list of a general surgeon will have up to 50% cases, which can be discharged on the same day.

Considering the many fold advantages of day care surgery, more can be done towards the refinement and ‘passing on’ of the advantages to the patients.

Our Centre has been instituted with the aim of developing Day Care or Ambulatory surgery into a speciality. We take this centre as an example to highlight the possibility and need for more of such centres in our Country.

This is a retrospective analysis of 1995 procedures performed at the centre, over a period of 2 1/2 years, from June 2000 to Dec. 2002.

Operative procedures were 1,363; Endoscopic procedures were 632 in number.
All the operative procedures were mostly done under local anaesthesia and sedation.

INTRODUCTION
History of Day Care or Ambulatory surgery is as old as medicine itself. Ancient instruments and evidence of Sushrut's work have been recorded long before modern medicine took birth. Over the centuries, the most respected healer, The Surgeon, has refined his speciality into an art form. In the present century, with the better understanding of the healing process, increase in surgical skills, availability of better anaesthetic drugs, and the want to do something new, which is beneficial to the patient and you; has led to the development of Day care surgery or Ambulatory surgeries into an art in itself.

Definitions of Day Care Surgery have varied from country to country, The Day Surgery Operational guide, issued by the Department of Health, U.K., has described Day Surgery as: the admission of selected patients to hospital for a planned surgical procedure, returning home on the same day. True day surgery patients are day case patients who require full operating theatre facility and/or a general anaesthetic, and any day cases not included as outpatient or endoscopy.1
The American author of the book ‘Major Ambulatory Surgery’, by Dr James E Davis, describes day care surgeries as Minor Ambulatory surgery or outpatient surgery, as that care provided to non-hospitalised patients with immediate discharge of the patient; local anaesthesia is almost invariably used. Whereas, Major Ambulatory surgery is defined as that surgery done under general, regional or local anaesthesia in which a period of postoperative recovery and/or observation is utilized before the patient is discharged home later the same day.2 These include cases hospitalised up to 23 hours from the time of admission.

MATERIAL AND METHODS
The place of study was our Centre in Mumbai.
The patients were operated during the period from June 2000 to Dec. 2002, that is, since the day care centre was started. During these 2 1/2 years, we have performed: 590 Surgical procedures, 773 OPD procedures and 632 Endoscopic procedures under local anaesthesia and some form of sedation.

The types of procedures done with their numbers are detailed in Table 1.
As of now, OPD cases and endoscopic procedures, in most of the countries, are not included in the day care surgery list; though, some of them do require a good amount of sedation and hence post operative recovery, therefore, cases should be individualised.

Endoscopic procedures done at the centre are as follows: (Table 2)
TABLE 2

Endoscopies Number of cases

1. Gastroscopy 360
2. Sigmoidoscopy 191
3. Colonoscopy 60
4. Cystoscopy 21


Criteria’s for Patient selection
• Age: more than 6 months old.
• Medically fit and stable patients {ASA I, II, III (well controlled)}.
• Well motivated and psychologically / mentally stable.
• Toilet, transport, telephone and responsible relation at home.
• Body mass index > 35.
Patient preparation
• Examination and diagnosis.
• Investigations (Haemogram, Bl. Sugar, HIV, HBsAg, Urine, Stool, X-ray Chest, ECG; USG, Liver and Kidney function-if indicated).
• Medical fitness (Physician/ Cardiologist/ Diabetologist/ Anaesthesiologist).
• Overnight fasting.
• Bowel preparation (Laxatives, enemas)
• Advise regarding pre-op. Medications (Inj.Tetanus Toxoid, Anti Hypertensive, to stop Aspirin at least 2 days before surgery).
• The use of alprazolam or any other mild sedative, on the previous night, helps in reducing the anxiety of the patient.
Anaesthesia used
Local anaesthesia:
• 2% Lignocaine HCl, with or without adrenaline
• 0.5% Bupivacaine
• Mixed in equal quantity
• Injected through a 26G or 27G Needle.
• On table sensitivity test is done in all cases
Blocks regularly used:
• Pudendal
• Ring
• Field
• Inguinal
• Scrotal / Cord
• Costal

General anaesthesia (Halothane and Nitrous Oxide, full doses of Ketamine, propofal, pentothal, scoline).
Short acting drugs and I.V. sedation (Midazolam, Small Doses of Ketamine, phenergan).

Contraindication for Day Care Surgery:
- Medically unfit for discharge on the same day
- Mental retardation / psychologically unstable
- Highly infectious disease
- Upper respiratory tract infection
- Premature or less than 6 month old babies
- Requiring extensive post-op. monitoring
- Long distance from home
- Shock / trauma
- High fever

Disadvantages of Day Care
• Poor patient acceptance
• Do not follow pre-op. instructions
• Inadequate facility at home for post-op. Care.
• Lack of responsible person to take care at home
• No facility for post-op. emergencies / complications at or near home
• Uncomfortable position during surgery, as patient is conscious
• Failure of block
Advantages of Day Care
• Reduced hospital stay
• Early resumption of day-to-day activity
• Cost effective
• Reduces anxiety of 'surgery'
• Recovery in familiar surroundings
• Reduces hospital-acquired infection
• Risks and side effects of G.A. are reduced
• Faster post-op. Recovery
• In cases where G.A. is contraindicated
• Less need for post-op. starvation
• Reduces the patient over load in the hospital
• Reduces ‘wait list‘ for surgery

PROCEDURE
Most of the patients are operated under local anaesthesia and sedation.
We extensively use local blocks and sedation is given in the form of Midazolam, phenergan with or without Pentazocin; and/or Ketamine, the combination given by our anaesthetist, is just to cover the pain of the local at the time of its injection, after which, we prefer our patient to be conscious and awake. Therefore, we avoid the repetition of the drugs, unless needed.

Once the local anaesthesia has acted, there is no pain and patient’s apprehension is reduced. Local used is 2% lignocaine with or without adrenaline and 0.5% bupivacaine, mixed in equal amount, injected through a 27 G needle.
History of sensitivity is taken prior to surgery and/or test dose is given on table.

Skin crease incisions are taken wherever possible, minimal dissection, sub-cuticular closure is done using fine absorbable suture material.

Patient is mobilized immediately, given orally within half to two hours.
Sent home after a maximum stay of 8 hours.
Verbal and written instructions are given to the patient and the accompanying person.
All the contact numbers of the team of doctors are given.
Regular follow up record is kept.

Criteria for discharge
- The patient is fully conscious
- Haemodynamically stable
- No giddiness on standing
- Able to walk without support
- Tolerating orally without vomiting
- No or minimal pain
- Passed urine
- Responsible person is present to take the patient home
- No surgical complications
On discharge
- Written instructions
- Verbal instructions
- Contact nos. of all our team, including the operating surgeons, in case of any questions and complications.
- Instruction on how to look for complications and its management.

COMPLICATION
• Reaction to local anaesthesia
• Giddiness, syncope, bradycardia
• Nausea, vomiting
• Retention of urine
• Severe pain at home
• Bleeding, haemorrhage, haematoma
Complications we faced
Appendicectomy: Four patients had to be hospitalised overnight out of 28, that is, 14.2%.
Haemorrhoidectomy: Two patients had to be hospitalised for secondary bleeding, managed conservatively, no transfusion had to be given. This was out of 179 patients operated, that is, 1.11%.
Bilateral hernioplasty: One patient had to be admitted due to excessive drowsiness, out of 61 hernioplasty, that is, 1.6%.
Four male patients, with underlying BPH, had to be catheterised post operatively; as they went into retention, they were discharged with the catheter.

DISCUSSION
A home visit by one of our team doctors or a phone call is mandatory for every patient before the centre is closed for the night. It is a good idea to include these visits as part of the package.
Day Care surgery, therefore, is a cost effective proposition, even in public hospital set up.3
Day care surgery purely as a speciality is still in its infancy in India.
Though most of the surgeons have been sending their patients home the same day, these cases are mostly done as part of their inpatient list, where the patients are hospitalised and have to undergo the same formalities as for indoor patients.
There is a need for more and more dedicated day care centres admitting patients and discharging from their facilities directly, which is more convenient. Patient can be called fasting in the morning of surgery, can be started on full diet within 2 to 3 hours, ambulation almost immediately, depending on the sedation given; and discharged on the same day. Managed by trained paramedical staff, general surgeons and anaesthetist.
Operation theatre should be fully equipped. Autoclaving and the peripheral equipment needed should be there.
Staff should include junior doctors, who are aware of day care procedures; and have been working with us and are trained by us to manage Day surgery cases.

Involvement of the referring doctor, especially the general practitioner, is invaluable; they are very beneficial in making sure that the patient follows the pre-operation instructions and help in the post-operative management.
The possibilities are many more, inclusion of laparoscopic surgeries for appendicectomy, hernia repair, and may be, cholecystectomy; mini-laparotomy and laparoscopic surgeries, as day care, have already been popularised by gynaecologist, its adaptation into general surgery, is not far behind.

CONCLUSION
Over the years, more and more cases have been added to the Day care list; still more needs to be done.
There is an urgent need for increasing awareness among the medical, as well as, non-medical fraternity.
This can be achieved by proper sharing of information on day care procedures with general practitioner and other referring doctors; carefully selected and well-motivated patients; no hospitalisation and early ambulation; skilled surgery and meticulous follow up; ensures good results, which are comparable, and even superior to hospitalised surgery.
Like world over, Day care surgery is going to be the need of the Day in India.

Lack of hospital beds, long waiting list, increasingly expensive health care system, virtually non existent medical insurance, lack of governmental funding to the private sector of health care, day care surgery seems to be the only answer, for the future.

‘Weather this patient should be sent home', needs to be changed to: ‘Does this patient need to be admitted?’

REFERENCES
1. Prof A Darzi, Dept. of Health, The Day Surgery Operational Guide, August 2002, U.K.,1-28.
2. Dr James E Davis. Major Ambulatory Surgery Today, 1987, USA, 33-57.
3. Dr RD Bapat, et al. Day Care Surgery in A Public Hospital Set Up, Bombay Hospital Journal, April 2001, vol.43, no. 2, pg. 249-252.
4. Mark Hitchcock Day Case Anaesthesia: the Surgical Perspective, Surgery, 1998, U.K. 141-4.

Advanced Plastic Surgery Procedures as Day Care
Ashok K Gupta*, Vinay Jacob**

The concept of office based procedures or Day Care procedures in Plastic and Aesthetic Surgery, has influenced the specialty dramatically. The factors driving this growth include patient preference, cost containment, physician autonomy and most of all, advancement in anaesthesia and techniques of minimal access.

Since most of the patients undergoing these procedures have an element of apprehension, the need has grown rapidly for office based conscious sedation. A general anaesthesia continuum exists for sedation that ranges from conscious sedation, followed by a deeper sedation, if the amount of drug is increased, and eventually, general anaesthesia.
The newer anaesthetic medications are extremely short acting and have minimal sequelae. Rapid and smoother emergence, followed by an early discharge has now become the usual norm.

Conscious sedation, (this, along with ‘maintained anaesthesia care’ (MAC) and ‘sedation and analgesia’ are all equivalent terms) describes a state that allows patients to tolerate unpleasant procedures, while maintaining adequate cardio-respiratory function and the ability to respond purposefully to verbal commands as well as tactile stimulation.
This is an obvious major advantage in those cases where we need the patient to co-operate at the time of surgery in order to evaluate the functional element of the surgery, as may be in the case of a tendon repair. While maintaining the basic monitoring standards and strict adherence to stringent patient selection, the surgeon must exercise his clinical acumen in selecting his choice of pain relief for the procedure from the available range of local or regional anaesthesia, with or without sedation, or the sedation continuum.

This sedation continuum, as has been mentioned earlier, varies from continuous sedation to deep sedation to general anaesthesia. The general anaesthesia too may be a Total Intravenous Anaesthesia (TIVA), or the Dissociative Anaesthesia, such that the patient may recover early and be discharged the same day.

With all precautions and care for each patient, the many varied procedures that are under the perview of the plastic surgeon can be accomplished with safety and the least margin of error. These can be segregated for the purpose of simplification under the following heads:-

1. Burns
2. Reconstructive Plastic Surgery
3. Aesthetic Plastic Surgery
5. Laser Surgery
6. Microsurgery
7. Craniofacial Surgery
8. Hand

Of these, the aesthetic, laser and hand cases form almost the entire gamut of the procedures that can be effectively done on a day care basis by the plastic surgeon. A few of the minor cases of simple reconstructions (especially trauma, surgical oncology and burns), micro and craniofacial surgery can also be undertaken. Those that are commonly performed have been briefly listed here.

BURNS
P R O C E D U R E ANAESTHESIA
1. Management of minor to moderate LA + RA +/-burns with tangential excision and Consc. Sedationskin grafting.
2. Scar revisions / release of LA + RA +/-Contracture and / or resurfacing with Sedationgrafts or local tissues / flaps.
3. Post Burn Contractures + Osteotomy LA + RA +/-
Consc. Sedation

RECONSTRUCTIVEPLASTICSURGERY
P R O C E D U R E ANAESTHESIA
1. Excision of small to moderate LA + RA +/-
benign lesions and reconstruction Consc. Sedation
with grafts or local flaps
2. Scar revisions / Serial excisions LA + RA +/-
Sedation
3. Placement of tissue expanders / LA + RA +/-
implants Sedation
4. Excisions for vascular anomalies and LA + RA +/-
dermatological lesions Sedation
5. Defect correction of the facial LA + RA +/-
structures scalp, cheek, eyelids, Sedation
ear, nose and lips
6. Genital area reconstruction for LA + RA +/-
congenital and traumatic condition Consc. Sedation
7. Post Hansen’s Disease deformities. LA + RA +/-
Consc. Sedation
8. BCC / Sq CC / MM of the skin LA + RA +/-
and adnexae Sedation
9. Wide excisions of recur. or suspected LA + RA +/-
lesions Sedation

CRANIOFACIALSURGERY
P R O C E D U R E ANAESTHESIA
1. Adult Cleft Lip repairs LA + RA +/- Sedation
2. Minor corrections of secondary LA + RA +/-cleft lip and nose deformities Sedation
3. Evaluation for velo-pharyngeal Surface Aincompetence and other similar shortdiagnostic procedures.
4. Simple facial bone fractures with no LA + RA +/-associated medical / surgery history Consc. Sedation
LASERPROCEDURESINPLASTIC SURGERY

P R O C E D U R E ANAESTHESIA
1. Depilation Surface A
2. Laser assisted hair transplantation Surface A
3. Laser Facial Rejuvenation for the Surface Aageing face
4. Laser Skin Resurfacing of surface Surface Airregularities
5. Laser tissue welding e.g. as in repair LA + RA +/-of hypospadias Sedation
6. Tattoo Removal Surface A
7. Tissue Incising lasers for superficial LA + RA +/-excisions Sedation
8. Treatment of Vascular lesions Surface A
9. Treatment of Pigmented lesions Surface A

HAND SURGERY
P R O C E D U R E ANAESTHESIA
1. Compression neuropathies LA + RA +/-(Carpal tunnel syndrome - SedationEndoscopic or the OpenProcedure for release )
2. Congenital hand deformities LA + RA +/-connections Consc. Sedation
3. Contracture release and resurfacing LA + RA +/- Consc. Sedation
4. Dupuytrens disease LA + RA +/- Sedation
5. Fractures and ligament injuries LA + RA +/- Consc. Sedation
6. Skin Grafts / Local Flaps in Hand LA + RA +/-(also, both extremities) Sedation
7. Stenosing tendovaginitis release LA + RA +/- Sedation
8. Tendon transfers LA + RA +/- Sedation

MICRO - SURGERY
P R O C E D U R E ANAESTHESIA
1. Simple digit replantations LA + RA +/-and / or revascularizations Consc. Sedation
2. Nerve repairs LA + RA +/- Sedation
3. Smaller Free Micro Vascular Flaps LA + RA +/- Consc. Sedation

AESTHETIC PLASTIC SURGERY
P R O C E D U R E ANAESTHESIA
1. Abdominoplasty LA + RA +/- Consc. Sedation
2. Blepharoplasty LA + RA +/- Consc. Sedation
3. Breast:

Augmentation mammoplasty LA + RA +/- Consc. Sedation
Reduction mammoplasty and mastopexy
Gynaecomastia - subcutaneous excision
Nipple Areola Reconstructions
4. Brow and Forehead lifts. LA + RA +/- Consc. Sedation
5. Chemical Peelings Surface A
6. Correction of landmark abnormalities LA + RA +/-of the face and other regions Consc. Sedation
7. Dermal Fillers LA
8. Endoscopic Plastic Surgery LA + RA +/- Consc. Sedation
9. Facial Contouring with Alloplastic LA + RA +/-implants Consc. Sedation
10. Liposuction and Body Contouring LA + RA +/- Consc. Sedation
11. Micro Hair Transplantations LA + RA +/- Sedation
12. Nail surgeries LA + RA
13. Osseous Genioplasty LA + RA +/- Consc. Sedation
14. Rhinoplasty LA + RA +/- Consc. Sedation
15. Rhytidectomy / Face Lifts LA + RA +/- Consc. Sedation

ENDOSCOPIC PLASTIC PROCEDURES
P R O C E D U R E ANAESTHESIA
1. Abdominoplasty LA + RA +/- Consc. Sedation
2. Aesthetic facial surgery - Facelift, LA + RA +/-Forehead lift and Cervicoplasty Consc. Sedation
3. Breast augmentation, reduction, LA + RA +/-Ptosis correction and Capsule Consc. Sedationinspection
4. Facial skeletal surgery LA + RA +/- Consc. Sedation
5. Inspection of flaps, tendon retrieval, LA + RA +/-neurolysis, ligation of perforators Consc. Sedationand evacuation of hematoma
6. Lipoma excision LA + RA +/- Sedation
7. Static sling placement in facial LA + RA +/-palsy Consc. Sedation
8. Tissue Expander placement LA + RA +/- Consc. Sedation
9. Tissue harvest - e.g. Latissimus LA + RA +/-dorsi muscle flap Consc. Sedation

BRIEFDESCRIPTIONOFTHECOMMONLY DONEPLASTICSURGERYPROCEDURESON ADAYCAREBASIS
LIPOSUCTION AND BODY CONTOURING

There are surgical techniques designed to improve the appearance of any area of the body by a combination of fat aspiration, skin excision and musculo - aponeurotic tightening, especially of the arms, trunk and lower extremities.
Liposuction or vacuum aspiration of the subcutaneous fat, through small-concealed incisions.
Pre-operative marking, photographing the patient, patient positioning and tumescent fluid infiltration are carefully executed prior to the procedure (Fig. 1).

With healing, the overlying skin shrinks to the reduced fat volume and the contour is diminished.
The instrumentation required, are the special small, medium and large cannulae, which have specific openings of different shapes and sizes, a flexible, non-collapsible tubing attached to an aspirating pump, that achieves enough vapour pressure (as vaporization of water in aspirated tissues significantly increases the flow rate).
Pressure garments and graded exercising are explained to the patient in the postoperative period along with better diet control and regular physical workouts.

ABDOMINOPLASTY
Patients seeking abdominoplasty, are classified in various treatment categories wherein either a liposuction, skin and subcutaneous tissue excision, rectus / abdominal wall muscle placation and an umbilical relocation may be required, either singly, or in a combination of the above.

Pre-operative markings are done with the patient in the standing position. The scar is designed so that the lateral portion is high and does not appear beneath bathing suits that are cut high on the sides.
The eventual extent of excision is determined best at surgery and may be more or less than indicated by the pre-operative markings (Fig. 2).

ENDOSCOPIC PLASTIC SURGERY
Though they have a long history, only recently have they begun to have broad application in plastic surgery, especially with the brilliant combination of the video technologies to the endoscopes, seen best in the late 1980’s with the laparoscopic cholecystectomy.

a) Endoscopic Brow Lift
The endoscopic brow lift is achieved by three to five incisions placed anteriorly within the scalp for the instruments to be placed to allow for dissections (Fig. 3).

b) Endoscopic Trans-axillary Breast Augmentation
Endoscopic Trans-axillary ( or even trans - umbilical), augmentation mammoplasty is done by creating an optical cavity and placing the implant as is done in a regular open method.
The other areas where this method is routinely employed is for the harvestation of various subcutaneous structures, especially the Latissimus dorsi muscle flap for the various reconstructions, as an adjunct in abdominoplasty and liposuctions and more recently, investigations are underway to assess its role in the techniques of various facial osteotomies and bone distraction.

AUGMENTATION MAMMOPLASTY
The modern mammary prosthesis, exemplified formerly by the silicone gel implant, is actually a mixture of polymers comprised principally of polydimethyl siloxane that can exist in the form of a solid, liquid or a gel.
The infra-mammary incision is preferred for the placement of the implant in those cases that have a fairly well developed infra-mammary crease that conceals the scar.

While the patient can return home the same day, she can return to her job in a few days, depending on the level of activity required at her place of work (Fig. 4).

The decision to have a breast augmentation is a personal one that not everyone will understand. The important thing is how the patient feels about it, and if her goals are met, then the surgery is a success.

REDUCTION MAMMOPLASTY
This procedure is a classic example of the interface between reconstructive and aesthetic plastic surgery, with a goal of weight and volume reduction of the breast along with an aesthetic enhancement (Fig. 5).

RHINOPLASTY
The rhinoplasty is amongst the most challenging of all the aesthetic operations as the nasal anatomy is highly variable and precludes a simple standard operation. Besides both: form and function being needed to be rectified, the highly visible nature of the eventual result must meet the patients’ high expectation.

The first decision in whether to use an open, closed or a closed / open approach. Ideal landmarks are marked pre - operatively and though the surgery can be executed under local anaesthesia, it is preferable under general anaesthesia.
The splinting is the final procedure in a rhinoplasty and is done meticulously with utmost care. This dorsal nasal splint is maintained for about a week or so, when even the sutures can be removed (Fig. 6).

HAIRTRANSPLANTATION
Hair transplantation is based on the concept of donor dominance in male pattern baldness (MPB), which is that, if a hair follicular graft is taken from an area destined to be permanently hair bearing, and is transplanted into an area of MPB, it will eventually, after a while of regression, continue to grow in its new site, as long as it would have had done at its original site (Fig. 7).

REFERENCES
1. Abergel RP, David LM. Aging Hands: A Technique Of Hand Rejuvenation By Laser Resurfacing And Autologus Fat Transfer. J Dermatol Surg Oncol 1989; 15 : 725-8.
2. Agban MG. Augmentation And Corrective Malarplasty. In Lewis J (Ed): The Art Of Plastic Surgery. Boston, Little, Brown, 1989; 543.
3. Agbon C. Augmentation And Corrective Malarplasty. Ann Plast Surg 1979; 2 : 306.
4. Barrent A, Whitaker LA. Facial Form Analysis Of The Lower And Middle Face. Plast Reconstr Surg 1986,78:158.
5. Barry E, Dibernardo Et al. Laser Hair Removal. In CPS, April 2000; Vol 27. Number 2 : 199-211.
6. Di Bernardo BE, et al. Laser Hair Removal. Where Are We Now? 1999; PRS 104(!) : 247-57.
7. Dover JS, et al. Illustrated Cutaneous Surgery: A Practitioners Guide. Norwalk, CT, Appelton and Lange, 1990; 45-8.
8. Fitzpatrick RE. Use Of The Ultra Pulse CO2 Laser For Dermatology Including Facial Resurfacing. American Society For Laser Medicine And Surgery Abstracts (#234), P 50. San Diego, CA, April 2-4, 1995 (Wiley-Liss, Inc.).p-4-8.
9. Fitzpatrick TB, et al. Dermat. In Gen. Medicine, Ed 2, NY, Mc Graw Hill, 1997.
10. Goldberg DJ, Et al. Effect Of The Laser Beam On The Skin: J of Invest Dermatol 1963; 40 : 121-2.
11. Goldberg DJ, et al. Topical - Suspension Assisted Q-Switched Nd:YAG Laser Hair Removal. Dermatol Surg 1997; 23 : 741-5.
12. Groner R, et al. Endoscopic Harvesting of The Latissimus Dorsi Muscle Flap. Eur. Journal of Plastic Surgery 1997; 20 : 4.
13. Hinderar U. Malar Implants For Improvement of the Facial Appearance. Plast Reconstr Surg 1975; 56 : 157.
14. Miller MJ. Minimally Invasive Technique of Tissue Harvest In Head and Neck Reconstruction. In Clinics In Plastic Surgery. 1994; 21 : 149.
15. Operating Instructions PB 2300410 Rev. B: Esc Sharplan, Aug 2000.
16. Ortiz Moansterio. The Application Of Craniofacial Surgery To Aesthetic Surgery. In Jackson IT (Ed): Recent Advances In Plastic Surgery. Edinburgh, Churchil Livingstone, 1981; 52-9.
17. Whitaker LA, Barlette SP. Aesthetic Surgery Of The Facial Skeleton. Perspect. Plast Surg 1988; 2 : 23.
18. Whitaker LA, Morales L,Farkas LG. Aesthetic Surgery of the Supraorbital Ridge And Forehead Structures. PRS, 1986; 78 : 23.
19. Wilkinson T. Complications In Aesthetic Malar Augmentation. Plast Reconstr Surg 1983; 7 : 643.


Ambulatory Surgery in Children
Kishore Adyanthaya*, Amrish Vaidya**, Vrishali Patil***

Day Care or Ambulatory surgery is rapidly developing in our country. A regular list of a general surgeon will have up to 50% cases, which can be discharged on the same day.
Considering the many fold advantages of day care surgery, more can be done towards the refinement and ‘passing on’ of the advantages to the patients.
Our Centre has been instituted with the aim of developing Day Care or Ambulatory surgery into a speciality. We take this centre as an example to highlight the possibility and need for more of such centres in our Country.
This is a retrospective analysis of 1995 procedures performed at the centre, over a period of 2 1/2 years, from June 2000 to Dec. 2002.
Operative procedures were 1,363; Endoscopic procedures were 632 in number.
All the operative procedures were mostly done under local anaesthesia and sedation.
INTRODUCTION
History of Day Care or Ambulatory surgery is as old as medicine itself. Ancient instruments and evidence of Sushrut's work have been recorded long before modern medicine took birth. Over the centuries, the most respected healer, The Surgeon, has refined his speciality into an art form. In the present century, with the better understanding of the healing process, increase in surgical skills, availability of better anaesthetic drugs, and the want to do something new, which is beneficial to the patient and you; has led to the development of Day care surgery or Ambulatory surgeries into an art in itself.
Definitions of Day Care Surgery have varied from country to country, The Day Surgery Operational guide, issued by the Department of Health, U.K., has described Day Surgery as: the admission of selected patients to hospital for a planned surgical procedure, returning home on the same day. True day surgery patients are day case patients who require full operating theatre facility and/or a general anaesthetic, and any day cases not included as outpatient or endoscopy.1
The American author of the book ‘Major Ambulatory Surgery’, by Dr James E Davis, describes day care surgeries as Minor Ambulatory surgery or outpatient surgery, as that care provided to non-hospitalised patients with immediate discharge of the patient; local anaesthesia is almost invariably used. Whereas, Major Ambulatory surgery is defined as that surgery done under general, regional or local anaesthesia in which a period of postoperative recovery and/or observation is utilized before the patient is discharged home later the same day.2 These include cases hospitalised up to 23 hours from the time of admission.
MATERIAL AND METHODS
The place of study was our Centre in Mumbai.
The patients were operated during the period from June 2000 to Dec. 2002, that is, since the day care centre was started. During these 2 1/2 years, we have performed: 590 Surgical procedures, 773 OPD procedures and 632 Endoscopic procedures under local anaesthesia and some form of sedation.
The types of procedures done with their numbers are detailed in Table 1.
As of now, OPD cases and endoscopic procedures, in most of the countries, are not included in the day care surgery list; though, some of them do require a good amount of sedation and hence post operative recovery, therefore, cases should be individualised.
Endoscopic procedures done at the centre are as follows: (Table 2)
TABLE 2

Endoscopies Number of cases

1. Gastroscopy 360
2. Sigmoidoscopy 191
3. Colonoscopy 60
4. Cystoscopy 21


Criteria’s for Patient selection
• Age: more than 6 months old.
• Medically fit and stable patients {ASA I, II, III (well controlled)}.
• Well motivated and psychologically / mentally stable.
• Toilet, transport, telephone and responsible relation at home.
• Body mass index > 35.
Patient preparation
• Examination and diagnosis.
• Investigations (Haemogram, Bl. Sugar, HIV, HBsAg, Urine, Stool, X-ray Chest, ECG; USG, Liver and Kidney function-if indicated).
• Medical fitness (Physician/ Cardiologist/ Diabetologist/ Anaesthesiologist).
• Overnight fasting.
• Bowel preparation (Laxatives, enemas)
• Advise regarding pre-op. Medications (Inj.Tetanus Toxoid, Anti Hypertensive, to stop Aspirin at least 2 days before surgery).
• The use of alprazolam or any other mild sedative, on the previous night, helps in reducing the anxiety of the patient.
Anaesthesia used
Local anaesthesia:
• 2% Lignocaine HCl, with or without adrenaline
• 0.5% Bupivacaine
• Mixed in equal quantity
• Injected through a 26G or 27G Needle.
• On table sensitivity test is done in all cases
Blocks regularly used:
• Pudendal
• Ring
• Field
• Inguinal
• Scrotal / Cord
• Costal
General anaesthesia (Halothane and Nitrous Oxide, full doses of Ketamine, propofal, pentothal, scoline).
Short acting drugs and I.V. sedation (Midazolam, Small Doses of Ketamine, phenergan).
Contraindication for Day Care Surgery:
- Medically unfit for discharge on the same day
- Mental retardation / psychologically unstable
- Highly infectious disease
- Upper respiratory tract infection
- Premature or less than 6 month old babies
- Requiring extensive post-op. monitoring
- Long distance from home
- Shock / trauma
- High fever
Disadvantages of Day Care
• Poor patient acceptance
• Do not follow pre-op. instructions
• Inadequate facility at home for post-op. Care.
• Lack of responsible person to take care at home
• No facility for post-op. emergencies / complications at or near home
• Uncomfortable position during surgery, as patient is conscious
• Failure of block
Advantages of Day Care
• Reduced hospital stay
• Early resumption of day-to-day activity
• Cost effective
• Reduces anxiety of 'surgery'
• Recovery in familiar surroundings
• Reduces hospital-acquired infection
• Risks and side effects of G.A. are reduced
• Faster post-op. Recovery
• In cases where G.A. is contraindicated
• Less need for post-op. starvation
• Reduces the patient over load in the hospital
• Reduces ‘wait list‘ for surgery
PROCEDURE
Most of the patients are operated under local anaesthesia and sedation.
We extensively use local blocks and sedation is given in the form of Midazolam, phenergan with or without Pentazocin; and/or Ketamine, the combination given by our anaesthetist, is just to cover the pain of the local at the time of its injection, after which, we prefer our patient to be conscious and awake. Therefore, we avoid the repetition of the drugs, unless needed.
Once the local anaesthesia has acted, there is no pain and patient’s apprehension is reduced. Local used is 2% lignocaine with or without adrenaline and 0.5% bupivacaine, mixed in equal amount, injected through a 27 G needle.
History of sensitivity is taken prior to surgery and/or test dose is given on table.
Skin crease incisions are taken wherever possible, minimal dissection, sub-cuticular closure is done using fine absorbable suture material.
Patient is mobilized immediately, given orally within half to two hours.
Sent home after a maximum stay of 8 hours.
Verbal and written instructions are given to the patient and the accompanying person.
All the contact numbers of the team of doctors are given.
Regular follow up record is kept.
Criteria for discharge
- The patient is fully conscious
- Haemodynamically stable
- No giddiness on standing
- Able to walk without support
- Tolerating orally without vomiting
- No or minimal pain
- Passed urine
- Responsible person is present to take the patient home
- No surgical complications
On discharge
- Written instructions
- Verbal instructions
- Contact nos. of all our team, including the operating surgeons, in case of any questions and complications.
- Instruction on how to look for complications and its management.
COMPLICATION
• Reaction to local anaesthesia
• Giddiness, syncope, bradycardia
• Nausea, vomiting
• Retention of urine
• Severe pain at home
• Bleeding, haemorrhage, haematoma
Complications we faced
Appendicectomy: Four patients had to be hospitalised overnight out of 28, that is, 14.2%.
Haemorrhoidectomy: Two patients had to be hospitalised for secondary bleeding, managed conservatively, no transfusion had to be given. This was out of 179 patients operated, that is, 1.11%.
Bilateral hernioplasty: One patient had to be admitted due to excessive drowsiness, out of 61 hernioplasty, that is, 1.6%.
Four male patients, with underlying BPH, had to be catheterised post operatively; as they went into retention, they were discharged with the catheter.
DISCUSSION
A home visit by one of our team doctors or a phone call is mandatory for every patient before the centre is closed for the night. It is a good idea to include these visits as part of the package.
Day Care surgery, therefore, is a cost effective proposition, even in public hospital set up.3
Day care surgery purely as a speciality is still in its infancy in India.
Though most of the surgeons have been sending their patients home the same day, these cases are mostly done as part of their inpatient list, where the patients are hospitalised and have to undergo the same formalities as for indoor patients.
There is a need for more and more dedicated day care centres admitting patients and discharging from their facilities directly, which is more convenient. Patient can be called fasting in the morning of surgery, can be started on full diet within 2 to 3 hours, ambulation almost immediately, depending on the sedation given; and discharged on the same day. Managed by trained paramedical staff, general surgeons and anaesthetist.
Operation theatre should be fully equipped. Autoclaving and the peripheral equipment needed should be there.
Staff should include junior doctors, who are aware of day care procedures; and have been working with us and are trained by us to manage Day surgery cases.
Involvement of the referring doctor, especially the general practitioner, is invaluable; they are very beneficial in making sure that the patient follows the pre-operation instructions and help in the post-operative management.
The possibilities are many more, inclusion of laparoscopic surgeries for appendicectomy, hernia repair, and may be, cholecystectomy; mini-laparotomy and laparoscopic surgeries, as day care, have already been popularised by gynaecologist, its adaptation into general surgery, is not far behind.
CONCLUSION
Over the years, more and more cases have been added to the Day care list; still more needs to be done.
There is an urgent need for increasing awareness among the medical, as well as, non-medical fraternity.
This can be achieved by proper sharing of information on day care procedures with general practitioner and other referring doctors; carefully selected and well-motivated patients; no hospitalisation and early ambulation; skilled surgery and meticulous follow up; ensures good results, which are comparable, and even superior to hospitalised surgery.
Like world over, Day care surgery is going to be the need of the Day in India.
Lack of hospital beds, long waiting list, increasingly expensive health care system, virtually non existent medical insurance, lack of governmental funding to the private sector of health care, day care surgery seems to be the only answer, for the future.
‘Weather this patient should be sent home', needs to be changed to: ‘Does this patient need to be admitted?’
REFERENCES
1. Prof A Darzi, Dept. of Health, The Day Surgery Operational Guide, August 2002, U.K.,1-28.
2. Dr James E Davis. Major Ambulatory Surgery Today, 1987, USA, 33-57.
3. Dr RD Bapat, et al. Day Care Surgery in A Public Hospital Set Up, Bombay Hospital Journal, April 2001, vol.43, no. 2, pg. 249-252.
4. Mark Hitchcock Day Case Anaesthesia: the Surgical Perspective, Surgery, 1998, U.K. 141-4.

Advanced Plastic Surgery Procedures as Day Care
Ashok K Gupta*, Vinay Jacob**
The concept of office based procedures or Day Care procedures in Plastic and Aesthetic Surgery, has influenced the specialty dramatically. The factors driving this growth include patient preference, cost containment, physician autonomy and most of all, advancement in anaesthesia and techniques of minimal access.
Since most of the patients undergoing these procedures have an element of apprehension, the need has grown rapidly for office based conscious sedation. A general anaesthesia continuum exists for sedation that ranges from conscious sedation, followed by a deeper sedation, if the amount of drug is increased, and eventually, general anaesthesia.
The newer anaesthetic medications are extremely short acting and have minimal sequelae. Rapid and smoother emergence, followed by an early discharge has now become the usual norm.
Conscious sedation, (this, along with ‘maintained anaesthesia care’ (MAC) and ‘sedation and analgesia’ are all equivalent terms) describes a state that allows patients to tolerate unpleasant procedures, while maintaining adequate cardio-respiratory function and the ability to respond purposefully to verbal commands as well as tactile stimulation.
This is an obvious major advantage in those cases where we need the patient to co-operate at the time of surgery in order to evaluate the functional element of the surgery, as may be in the case of a tendon repair. While maintaining the basic monitoring standards and strict adherence to stringent patient selection, the surgeon must exercise his clinical acumen in selecting his choice of pain relief for the procedure from the available range of local or regional anaesthesia, with or without sedation, or the sedation continuum.
This sedation continuum, as has been mentioned earlier, varies from continuous sedation to deep sedation to general anaesthesia. The general anaesthesia too may be a Total Intravenous Anaesthesia (TIVA), or the Dissociative Anaesthesia, such that the patient may recover early and be discharged the same day.
With all precautions and care for each patient, the many varied procedures that are under the perview of the plastic surgeon can be accomplished with safety and the least margin of error. These can be segregated for the purpose of simplification under the following heads:-
1. Burns
2. Reconstructive Plastic Surgery
3. Aesthetic Plastic Surgery
5. Laser Surgery
6. Microsurgery
7. Craniofacial Surgery
8. Hand
Of these, the aesthetic, laser and hand cases form almost the entire gamut of the procedures that can be effectively done on a day care basis by the plastic surgeon. A few of the minor cases of simple reconstructions (especially trauma, surgical oncology and burns), micro and craniofacial surgery can also be undertaken. Those that are commonly performed have been briefly listed here.
BURNS
P R O C E D U R E ANAESTHESIA
1. Management of minor to moderate LA + RA +/-burns with tangential excision and Consc. Sedationskin grafting.
2. Scar revisions / release of LA + RA +/-Contracture and / or resurfacing with Sedationgrafts or local tissues / flaps.
3. Post Burn Contractures + Osteotomy LA + RA +/-
Consc. Sedation

RECONSTRUCTIVEPLASTICSURGERY
P R O C E D U R E ANAESTHESIA
1. Excision of small to moderate LA + RA +/-
benign lesions and reconstruction Consc. Sedation
with grafts or local flaps
2. Scar revisions / Serial excisions LA + RA +/-
Sedation
3. Placement of tissue expanders / LA + RA +/-
implants Sedation
4. Excisions for vascular anomalies and LA + RA +/-
dermatological lesions Sedation
5. Defect correction of the facial LA + RA +/-
structures scalp, cheek, eyelids, Sedation
ear, nose and lips
6. Genital area reconstruction for LA + RA +/-
congenital and traumatic condition Consc. Sedation
7. Post Hansen’s Disease deformities. LA + RA +/-
Consc. Sedation
8. BCC / Sq CC / MM of the skin LA + RA +/-
and adnexae Sedation
9. Wide excisions of recur. or suspected LA + RA +/-
lesions Sedation

CRANIOFACIALSURGERY
P R O C E D U R E ANAESTHESIA
1. Adult Cleft Lip repairs LA + RA +/- Sedation
2. Minor corrections of secondary LA + RA +/-cleft lip and nose deformities Sedation
3. Evaluation for velo-pharyngeal Surface Aincompetence and other similar shortdiagnostic procedures.
4. Simple facial bone fractures with no LA + RA +/-associated medical / surgery history Consc. Sedation
LASERPROCEDURESINPLASTIC SURGERY
P R O C E D U R E ANAESTHESIA
1. Depilation Surface A
2. Laser assisted hair transplantation Surface A
3. Laser Facial Rejuvenation for the Surface Aageing face
4. Laser Skin Resurfacing of surface Surface Airregularities
5. Laser tissue welding e.g. as in repair LA + RA +/-of hypospadias Sedation
6. Tattoo Removal Surface A
7. Tissue Incising lasers for superficial LA + RA +/-excisions Sedation
8. Treatment of Vascular lesions Surface A
9. Treatment of Pigmented lesions Surface A

HAND SURGERY
P R O C E D U R E ANAESTHESIA
1. Compression neuropathies LA + RA +/-(Carpal tunnel syndrome - SedationEndoscopic or the OpenProcedure for release )
2. Congenital hand deformities LA + RA +/-connections Consc. Sedation
3. Contracture release and resurfacing LA + RA +/- Consc. Sedation
4. Dupuytrens disease LA + RA +/- Sedation
5. Fractures and ligament injuries LA + RA +/- Consc. Sedation
6. Skin Grafts / Local Flaps in Hand LA + RA +/-(also, both extremities) Sedation
7. Stenosing tendovaginitis release LA + RA +/- Sedation
8. Tendon transfers LA + RA +/- Sedation

MICRO - SURGERY
P R O C E D U R E ANAESTHESIA
1. Simple digit replantations LA + RA +/-and / or revascularizations Consc. Sedation
2. Nerve repairs LA + RA +/- Sedation
3. Smaller Free Micro Vascular Flaps LA + RA +/- Consc. Sedation

AESTHETIC PLASTIC SURGERY
P R O C E D U R E ANAESTHESIA
1. Abdominoplasty LA + RA +/- Consc. Sedation
2. Blepharoplasty LA + RA +/- Consc. Sedation
3. Breast:
Augmentation mammoplasty LA + RA +/- Consc. Sedation
Reduction mammoplasty and mastopexy
Gynaecomastia - subcutaneous excision
Nipple Areola Reconstructions
4. Brow and Forehead lifts. LA + RA +/- Consc. Sedation
5. Chemical Peelings Surface A
6. Correction of landmark abnormalities LA + RA +/-of the face and other regions Consc. Sedation
7. Dermal Fillers LA
8. Endoscopic Plastic Surgery LA + RA +/- Consc. Sedation
9. Facial Contouring with Alloplastic LA + RA +/-implants Consc. Sedation
10. Liposuction and Body Contouring LA + RA +/- Consc. Sedation
11. Micro Hair Transplantations LA + RA +/- Sedation
12. Nail surgeries LA + RA
13. Osseous Genioplasty LA + RA +/- Consc. Sedation
14. Rhinoplasty LA + RA +/- Consc. Sedation
15. Rhytidectomy / Face Lifts LA + RA +/- Consc. Sedation

ENDOSCOPIC PLASTIC PROCEDURES
P R O C E D U R E ANAESTHESIA
1. Abdominoplasty LA + RA +/- Consc. Sedation
2. Aesthetic facial surgery - Facelift, LA + RA +/-Forehead lift and Cervicoplasty Consc. Sedation
3. Breast augmentation, reduction, LA + RA +/-Ptosis correction and Capsule Consc. Sedationinspection
4. Facial skeletal surgery LA + RA +/- Consc. Sedation
5. Inspection of flaps, tendon retrieval, LA + RA +/-neurolysis, ligation of perforators Consc. Sedationand evacuation of hematoma
6. Lipoma excision LA + RA +/- Sedation
7. Static sling placement in facial LA + RA +/-palsy Consc. Sedation
8. Tissue Expander placement LA + RA +/- Consc. Sedation
9. Tissue harvest - e.g. Latissimus LA + RA +/-dorsi muscle flap Consc. Sedation

BRIEFDESCRIPTIONOFTHECOMMONLY DONEPLASTICSURGERYPROCEDURESON ADAYCAREBASIS
LIPOSUCTION AND BODY CONTOURING

There are surgical techniques designed to improve the appearance of any area of the body by a combination of fat aspiration, skin excision and musculo - aponeurotic tightening, especially of the arms, trunk and lower extremities.
Liposuction or vacuum aspiration of the subcutaneous fat, through small-concealed incisions.
Pre-operative marking, photographing the patient, patient positioning and tumescent fluid infiltration are carefully executed prior to the procedure (Fig. 1).
With healing, the overlying skin shrinks to the reduced fat volume and the contour is diminished.
The instrumentation required, are the special small, medium and large cannulae, which have specific openings of different shapes and sizes, a flexible, non-collapsible tubing attached to an aspirating pump, that achieves enough vapour pressure (as vaporization of water in aspirated tissues significantly increases the flow rate).
Pressure garments and graded exercising are explained to the patient in the postoperative period along with better diet control and regular physical workouts.
ABDOMINOPLASTY
Patients seeking abdominoplasty, are classified in various treatment categories wherein either a liposuction, skin and subcutaneous tissue excision, rectus / abdominal wall muscle placation and an umbilical relocation may be required, either singly, or in a combination of the above.
Pre-operative markings are done with the patient in the standing position. The scar is designed so that the lateral portion is high and does not appear beneath bathing suits that are cut high on the sides.
The eventual extent of excision is determined best at surgery and may be more or less than indicated by the pre-operative markings (Fig. 2).
ENDOSCOPIC PLASTIC SURGERY
Though they have a long history, only recently have they begun to have broad application in plastic surgery, especially with the brilliant combination of the video technologies to the endoscopes, seen best in the late 1980’s with the laparoscopic cholecystectomy.
a) Endoscopic Brow Lift
The endoscopic brow lift is achieved by three to five incisions placed anteriorly within the scalp for the instruments to be placed to allow for dissections (Fig. 3).
b) Endoscopic Trans-axillary Breast Augmentation
Endoscopic Trans-axillary ( or even trans - umbilical), augmentation mammoplasty is done by creating an optical cavity and placing the implant as is done in a regular open method.
The other areas where this method is routinely employed is for the harvestation of various subcutaneous structures, especially the Latissimus dorsi muscle flap for the various reconstructions, as an adjunct in abdominoplasty and liposuctions and more recently, investigations are underway to assess its role in the techniques of various facial osteotomies and bone distraction.
AUGMENTATION MAMMOPLASTY
The modern mammary prosthesis, exemplified formerly by the silicone gel implant, is actually a mixture of polymers comprised principally of polydimethyl siloxane that can exist in the form of a solid, liquid or a gel.
The infra-mammary incision is preferred for the placement of the implant in those cases that have a fairly well developed infra-mammary crease that conceals the scar.
While the patient can return home the same day, she can return to her job in a few days, depending on the level of activity required at her place of work (Fig. 4).
The decision to have a breast augmentation is a personal one that not everyone will understand. The important thing is how the patient feels about it, and if her goals are met, then the surgery is a success.
REDUCTION MAMMOPLASTY
This procedure is a classic example of the interface between reconstructive and aesthetic plastic surgery, with a goal of weight and volume reduction of the breast along with an aesthetic enhancement (Fig. 5).
RHINOPLASTY
The rhinoplasty is amongst the most challenging of all the aesthetic operations as the nasal anatomy is highly variable and precludes a simple standard operation. Besides both: form and function being needed to be rectified, the highly visible nature of the eventual result must meet the patients’ high expectation.
The first decision in whether to use an open, closed or a closed / open approach. Ideal landmarks are marked pre - operatively and though the surgery can be executed under local anaesthesia, it is preferable under general anaesthesia.
The splinting is the final procedure in a rhinoplasty and is done meticulously with utmost care. This dorsal nasal splint is maintained for about a week or so, when even the sutures can be removed (Fig. 6).
HAIRTRANSPLANTATION
Hair transplantation is based on the concept of donor dominance in male pattern baldness (MPB), which is that, if a hair follicular graft is taken from an area destined to be permanently hair bearing, and is transplanted into an area of MPB, it will eventually, after a while of regression, continue to grow in its new site, as long as it would have had done at its original site (Fig. 7).
REFERENCES
1. Abergel RP, David LM. Aging Hands: A Technique Of Hand Rejuvenation By Laser Resurfacing And Autologus Fat Transfer. J Dermatol Surg Oncol 1989; 15 : 725-8.
2. Agban MG. Augmentation And Corrective Malarplasty. In Lewis J (Ed): The Art Of Plastic Surgery. Boston, Little, Brown, 1989; 543.
3. Agbon C. Augmentation And Corrective Malarplasty. Ann Plast Surg 1979; 2 : 306.
4. Barrent A, Whitaker LA. Facial Form Analysis Of The Lower And Middle Face. Plast Reconstr Surg 1986,78:158.
5. Barry E, Dibernardo Et al. Laser Hair Removal. In CPS, April 2000; Vol 27. Number 2 : 199-211.
6. Di Bernardo BE, et al. Laser Hair Removal. Where Are We Now? 1999; PRS 104(!) : 247-57.
7. Dover JS, et al. Illustrated Cutaneous Surgery: A Practitioners Guide. Norwalk, CT, Appelton and Lange, 1990; 45-8.
8. Fitzpatrick RE. Use Of The Ultra Pulse CO2 Laser For Dermatology Including Facial Resurfacing. American Society For Laser Medicine And Surgery Abstracts (#234), P 50. San Diego, CA, April 2-4, 1995 (Wiley-Liss, Inc.).p-4-8.
9. Fitzpatrick TB, et al. Dermat. In Gen. Medicine, Ed 2, NY, Mc Graw Hill, 1997.
10. Goldberg DJ, Et al. Effect Of The Laser Beam On The Skin: J of Invest Dermatol 1963; 40 : 121-2.
11. Goldberg DJ, et al. Topical - Suspension Assisted Q-Switched Nd:YAG Laser Hair Removal. Dermatol Surg 1997; 23 : 741-5.
12. Groner R, et al. Endoscopic Harvesting of The Latissimus Dorsi Muscle Flap. Eur. Journal of Plastic Surgery 1997; 20 : 4.
13. Hinderar U. Malar Implants For Improvement of the Facial Appearance. Plast Reconstr Surg 1975; 56 : 157.
14. Miller MJ. Minimally Invasive Technique of Tissue Harvest In Head and Neck Reconstruction. In Clinics In Plastic Surgery. 1994; 21 : 149.
15. Operating Instructions PB 2300410 Rev. B: Esc Sharplan, Aug 2000.
16. Ortiz Moansterio. The Application Of Craniofacial Surgery To Aesthetic Surgery. In Jackson IT (Ed): Recent Advances In Plastic Surgery. Edinburgh, Churchil Livingstone, 1981; 52-9.
17. Whitaker LA, Barlette SP. Aesthetic Surgery Of The Facial Skeleton. Perspect. Plast Surg 1988; 2 : 23.
18. Whitaker LA, Morales L,Farkas LG. Aesthetic Surgery of the Supraorbital Ridge And Forehead Structures. PRS, 1986; 78 : 23.
19. Wilkinson T. Complications In Aesthetic Malar Augmentation. Plast Reconstr Surg 1983; 7 : 643.


Ambulatory Surgery in Children
Kishore Adyanthaya*, Amrish Vaidya**, Vrishali Patil***

Introduction

Following sophisticated advances in the techniques of surgery and anaesthesia in children, several operations in children can be performed on a day care basis, or in an ambulatory surgery centre. Safe, efficient and cost-effective outpatient surgery offers unique clinical and psychological benefits.

Historical aspects
Scottish and British surgeons were the first to recognize the advantages of performing surgical procedures on infants and children in the outpatient department of their hospitals. It was started originally because of shortage of hospital beds and unreasonable scheduling delays and patients failed to receive proper benefits of timely treatment
In 1909, James MacNicoll1 performed over 7000 day care procedures in 10 years. He stated that admitting children for certain operations “constitutes a waste of resources of a children’s hospital”. He recognized that results were comparable to those in admitted patients, with significant savings to the patient and to the hospital, and further stated that “with a mother of average intelligence, assisted by advice from the hospital sister, the child fares better than in the hospital.’

As paediatric surgery developed, and more was known about the pathophysiology of certain surgical conditions in children, more operations were gradually added to the list of possible day care cases.

An example is the operation for an inguinal hernia in a child for which a simple herniotomy is performed, without the need of a plastic repair as was the case in earlier situations. This fact was recognized in Australia,2 and in Europe,3,4,5 since the late 1800s, however in the United States, surgeons,6,7,8 still persisted in performing the traditional repair followed by seven days stay in the hospital followed by two weeks of bed rest at home! Potts,8 though successful in changing the type of surgery for hernia repair, continued to admit his patients for three days for a herniotomy. He persisted in believing that the advantages claimed for outpatient surgery were in fact an excuse for inadequate hospital facilities in Scotland, till a study in the 1950s revealed that there was a significant rate of hospital related infections in children admitted for elective surgery.9 Finally, in the 1960s, the economic advantage of outpatient surgery hastened its acceptance,10 and it was soon realized that about 35% of all operations in children could be performed without the need for hospital admission. In 1972 Cloud presented a large series of wide varieties of case performed under endotracheal anaesthesia, thereby establishing its absolute safety. Outpatient surgery quickly gained momentum and surgical care of children acquired a new style.11-13 This success led significant changes to adult surgical care and today the fashion is to stay out of the hospital if possible. In the present day, it is stated that about 60% of all operations performed on children can be done on a day care setting.14-16
However, whether this can be replicated in the Indian setting needs to be examined.
Eligibility for day care surgery

Some of the Surgeries, which can be done on Day Care basis (Table 1)
Table 1

Adenoidectomy and Excision of branchial Myringotomy arch appendagesAntral puncture Otoscopy and removal of ear foreign bodies

Laryngoscopy
Excision of preauricular Umbilical hernia repaircysts and sinuses, and small Umbilical polypectomydermoids
Tonsillectomy (with or Cauterisation of umbilicalwithout adenoidectomy) granulomas
Torticollis correction Excision of umbilical sinuses
Excision of Thyroglossal cysts Inguinal herniotomyCervical lymph node biopsy Orchidopexy
Bronchoscopy and proceedures Circumcision
Oesophago/Gastroscopy Meatotomyand procedures Preputial separation
Frenulectomy- tongue Distal hypospadias repair
Gynaecomastia excision Cystoscopy
Excision of BCG Adenitis
Excision of Skin lesions Pilonidal sinus
Excision of subcutaneous Rectal biopsyswellings, cysts, etc. Anal dilation
Removal of stitch granulomas Rectal polypectomy
Suture removals Sigmoidoscopy
Excision or injection of Colostomy revisionhaemangiomas
Muscle biopsy
Nerve biopsy Dental surgery
Hickman’s Catheter insertion Laparoscopy / Procedures


The common feature of the above operations is that prolonged observation and intravenous fluids are not required, nor is the administration of parenteral drugs.
There are clear advantages of ambulatory surgery. From the economic and hospital management point of view, this is efficient and cost effective. There is a saving on the cost of hospital bed occupation and all the other costs associated with this. Also, nursing staff can be more effectively utilized in treating active in-patients who need more care. Studies have shown that there is a unit cost saving of between 19-68 %, depending on the operation performed.17
From the patient’s viewpoint, there is increased acceptance of the procedure if done on a day care setting, especially in children. Spending a night at the hospital, in an unfamiliar environment, with unfamiliar people around is stressful to a child, and will compound the stress experienced because of surgery, due to pain, immobility, etc.
An informed intelligent mother is generally capable of adequately nursing a child after most day care procedures. An advantage in the Indian scenario is the joint family, where responsibility for care of an operated child can be shared with other family members. The recent telecom revolution has also made the doctor, using a mobile telephone readily available to answer most queries, especially in our situation where home visits by community nurses is not possible, or where a dedicated help desk at a hospital or nursing home may not be available. However, an alert and co-operative general practitioner may be included in the team responsible for care after surgery.
Situations where day care surgery may not be possible are lack of basic hygienic living conditions, lack of ability to understand the required post operative care, and foresee possible problems, and residing far from the place of surgery, making it difficult to come back to the hospital in case of an emergency.
There is evidence that babies of less than 48 weeks, post conceptual age, have increased likelihood of developing post-operative apnoea and bradycardia. Although there is no consensus to the specific lower age, term infants under three month of age, and pre-term infants of less than 48 weeks, post conceptual age, are considered unsuitable for

day care surgery.18,19
Finally, a medically unfit child, who has other associated conditions that may complicate the post operative course, is obviously not suitable for day care surgery.

TheDayofSurgery
Ideally, parents are carefully counselled in advance and provided with written instructions. It is wise to obtain, informed consent in the office, when surgery is being planned, fully explaining the procedure, alternate treatment and common complications of the procedure. Most operations performed on children, are scheduled as early as possible, to include the required period of starvation in the routine sleep period. If necessary, the parents can be asked to sedate the child before bringing him to hospital. The patients should ideally be called one hour prior to the time of surgery, rather than “bolus admission system”, where all patients are called in the morning.
Most surgical procedures performed on children, especially the very young, are done using sedation or general anaesthesia. An experienced anaesthetist should perform a pre-operative check. We prefer to have the child receive sedation while with the parents to avoid separation anxiety. The use of local or regional blocks has been invaluable in minimizing the depth of anaesthesia and ensuring quick recovery as well as pain relief following surgery.
Following surgery, the child is observed in the recovery area till he is awake, and following assessment by the anaesthetist, can be discharged. A detailed set of instructions is handed over to the parents at the time of discharge.
Pain relief after surgery has been simplified with the use of effective analgesic suppositories, which are prescribed as appropriate.

Creating the Infrastructure
Whereas facilities, which will encourage day care, are existent in most private nursing homes, some major hospitals have still not recognized the value of day-care, and suitable spaces for recovery following surgery are not always available. In some institutions, cumbersome admission procedures are still required to be carried out. The provision of day-care beds, or the availability of economical day-care ‘package rates’, with a simplified registration protocol, would be welcome.

Also, at present, some insurance companies that reimburse patients for medical costs do not recognize the value of day care. There are several situations where overnight admission is recommended only to be able to forward a claim to the insurance company, even when there is no justification for the same on medical grounds. This appears self-defeating for an insurance company, where the cost of a hospital bed would have to be paid for.
TheFuture

Current U.K. day surgery involves admission, investigation or treatment, and discharge of suitable patients within one working day. In the USA the concept of ’23 hour stay’ day surgery has been developed, whereby patients are discharged following surgery within 24 hours of their admission. This will permit a much wider range of operations to be undertaken by allowing a longer period of monitored recovery.

CONCLUSION
In appropriate cases, day care surgery in children is safe and cost-effective, and should be utilized with greater frequency. Approximately 60% of surgeries performed by paediatric surgeons can and should be conducted in Day Care setting. Increased day surgery should help reduce the waiting period and improve access to inpatient beds. The selection of suitable patients and operation, proper parent’s education and good communication with general practitioners is the cornerstone of good day care surgical practice. The future day surgery is likely to include more intermediate operations, such as, laparoscopic surgeries which may require longer duration of post-operative stay.
REFERENCES
1. Nicoll JH. The Surgery of infancy. Br Med J 1909; 2 : 753.
2. Russell RH. The etiology and treatment of inguinal hernia in the young. Lancet 1899; 2 : 1353.
3. Herzfeld G. Hernia in infancy. Am J Surg 1939; 39 : 422.
4. Czerny V. Syudien zur radkalbehandlung der hernien. Wien med Wschr, 1877; 27 : 497.
5. Banks WM. Notes on radical cure of hernia- London, Harrison and Sons, 1884.
6. Ladd WE, Gross RE. Inguinal Hernia. In Abdominal surgery of Infancy and childhood. Philadelphia, W B Saunders, 1941.
7. Gross RE. Inguinal Hernia. In Surgery of Infancy and Childhood. Philadelphia, 1953.
8. Potts WJ , Riker WL, Lewis JE . Treatment of inguinal hernias in infants andchildren. ANN Surg 1959; 132 : 566.
9. Izant RJ. Non operative aspects of paediatric surgery. Report of 27 Ross pediatric research conference. Columbus, Ohio, 1957.
10. American Medical Association. Factors responsible for increasing costs of medical care. Chicago, American Medical Association, 1979.
11. Cloud DT, Reed WA, Ford JL. Surgi-center: A fresh concept in Outpatient Paediatric Surgery: J Paediatr Surgery 1972; 7 : 206.
12. Cloud DT. Outpatient paediatric Surgery. A Surgeons View. Intl Anaestheol Cli 1976; 14 : 130.
13. Reed RA, Ford JL. Development of an independent outpatient centre. Int Anaesthesiol Clin 1976; 14 : 130.
14. Cloud DT. Major ambulatory surgery of paediatric patient . In Davis JE.(Ed) Major Ambulatory Surgery, Baltimore Willams and Wilkins 1986.
15. Morse TS. Paediatric iutpatient surgery. J Paeiatr Surg1972; 7: 283.
16. Otherson HB, ClatworthyHW. Outpatient herniorraphy for infants. Am j Dis Child 1968; 116 : 78.
17. Presscott R J, Cuthbertome J, Fenwick N, et al. Economic aspect of day Care after operations for hernia and varicose veins. J Epidemiol Comm Health 1978; 32 : 222.
18. Kurth CD, Spitzer AR, Broemule AM. Post-operative apnoea in pre-term infants, anaesthesiology, 1987; 66 : 483-8.
19. Malone JH, Schwartz MZ, Tyson HRT. Out patient Inguinal Herniorraphy in pre-term infants-is it safe? J Pediatr Surg 1992; 27 : 203-8.
Further Reading:
- Commission on the provision of surgical services. Guidelines for DayCase Surgery. London: Royal College Of Surgeons of England,1992.
- NHS Management Executive. Report by the Day Surgery Task Force. London: HMSO, 1993.
- Schultz RC. Outpatient surgery from antiquity to present. In Schults RC (Ed.) Outpatient surgery. Chap 1, Philadelphia, Lea andFebiger, 1979.
- Davis JE (Ed) Major Ambulatory Surgery: Willams and Wilkins Baltimore 1986.
- Jarrett PEM. Day Case Surgery: Past and Future growth. Surgery 1997 ;15:4, 95.



Following sophisticated advances in the techniques of surgery and anaesthesia in children, several operations in children can be performed on a day care basis, or in an ambulatory surgery centre. Safe, efficient and cost-effective outpatient surgery offers unique clinical and psychological benefits.

Historical aspects
Scottish and British surgeons were the first to recognize the advantages of performing surgical procedures on infants and children in the outpatient department of their hospitals. It was started originally because of shortage of hospital beds and unreasonable scheduling delays and patients failed to receive proper benefits of timely treatment
In 1909, James MacNicoll1 performed over 7000 day care procedures in 10 years. He stated that admitting children for certain operations “constitutes a waste of resources of a children’s hospital”. He recognized that results were comparable to those in admitted patients, with significant savings to the patient and to the hospital, and further stated that “with a mother of average intelligence, assisted by advice from the hospital sister, the child fares better than in the hospital.’
As paediatric surgery developed, and more was known about the pathophysiology of certain surgical conditions in children, more operations were gradually added to the list of possible day care cases.

An example is the operation for an inguinal hernia in a child for which a simple herniotomy is performed, without the need of a plastic repair as was the case in earlier situations. This fact was recognized in Australia,2 and in Europe,3,4,5 since the late 1800s, however in the United States, surgeons,6,7,8 still persisted in performing the traditional repair followed by seven days stay in the hospital followed by two weeks of bed rest at home! Potts,8 though successful in changing the type of surgery for hernia repair, continued to admit his patients for three days for a herniotomy. He persisted in believing that the advantages claimed for outpatient surgery were in fact an excuse for inadequate hospital facilities in Scotland, till a study in the 1950s revealed that there was a significant rate of hospital related infections in children admitted for elective surgery.9 Finally, in the 1960s, the economic advantage of outpatient surgery hastened its acceptance,10 and it was soon realized that about 35% of all operations in children could be performed without the need for hospital admission. In 1972 Cloud presented a large series of wide varieties of case performed under endotracheal anaesthesia, thereby establishing its absolute safety. Outpatient surgery quickly gained momentum and surgical care of children acquired a new style.11-13 This success led significant changes to adult surgical care and today the fashion is to stay out of the hospital if possible. In the present day, it is stated that about 60% of all operations performed on children can be done on a day care setting.14-16

However, whether this can be replicated in the Indian setting needs to be examined.
Eligibility for day care surgery
Some of the Surgeries, which can be done on Day Care basis (Table 1)
Table 1

Adenoidectomy and Excision of branchial Myringotomy arch appendagesAntral puncture Otoscopy and removal of ear foreign bodies
Laryngoscopy
Excision of preauricular Umbilical hernia repaircysts and sinuses, and small Umbilical polypectomydermoids
Tonsillectomy (with or Cauterisation of umbilicalwithout adenoidectomy) granulomas
Torticollis correction Excision of umbilical sinuses
Excision of Thyroglossal cysts Inguinal herniotomyCervical lymph node biopsy Orchidopexy
Bronchoscopy and proceedures Circumcision
Oesophago/Gastroscopy Meatotomyand procedures Preputial separation
Frenulectomy- tongue Distal hypospadias repair
Gynaecomastia excision Cystoscopy
Excision of BCG Adenitis
Excision of Skin lesions Pilonidal sinus
Excision of subcutaneous Rectal biopsyswellings, cysts, etc. Anal dilation
Removal of stitch granulomas Rectal polypectomy
Suture removals Sigmoidoscopy
Excision or injection of Colostomy revisionhaemangiomas
Muscle biopsy
Nerve biopsy Dental surgery
Hickman’s Catheter insertion Laparoscopy / Procedures


The common feature of the above operations is that prolonged observation and intravenous fluids are not required, nor is the administration of parenteral drugs.

There are clear advantages of ambulatory surgery. From the economic and hospital management point of view, this is efficient and cost effective. There is a saving on the cost of hospital bed occupation and all the other costs associated with this. Also, nursing staff can be more effectively utilized in treating active in-patients who need more care. Studies have shown that there is a unit cost saving of between 19-68 %, depending on the operation performed.17
From the patient’s viewpoint, there is increased acceptance of the procedure if done on a day care setting, especially in children. Spending a night at the hospital, in an unfamiliar environment, with unfamiliar people around is stressful to a child, and will compound the stress experienced because of surgery, due to pain, immobility, etc.

An informed intelligent mother is generally capable of adequately nursing a child after most day care procedures. An advantage in the Indian scenario is the joint family, where responsibility for care of an operated child can be shared with other family members. The recent telecom revolution has also made the doctor, using a mobile telephone readily available to answer most queries, especially in our situation where home visits by community nurses is not possible, or where a dedicated help desk at a hospital or nursing home may not be available. However, an alert and co-operative general practitioner may be included in the team responsible for care after surgery.

Situations where day care surgery may not be possible are lack of basic hygienic living conditions, lack of ability to understand the required post operative care, and foresee possible problems, and residing far from the place of surgery, making it difficult to come back to the hospital in case of an emergency.

There is evidence that babies of less than 48 weeks, post conceptual age, have increased likelihood of developing post-operative apnoea and bradycardia. Although there is no consensus to the specific lower age, term infants under three month of age, and pre-term infants of less than 48 weeks, post conceptual age, are considered unsuitable for day care surgery.18,19

Finally, a medically unfit child, who has other associated conditions that may complicate the post operative course, is obviously not suitable for day care surgery.

TheDayofSurgery
Ideally, parents are carefully counselled in advance and provided with written instructions. It is wise to obtain, informed consent in the office, when surgery is being planned, fully explaining the procedure, alternate treatment and common complications of the procedure. Most operations performed on children, are scheduled as early as possible, to include the required period of starvation in the routine sleep period. If necessary, the parents can be asked to sedate the child before bringing him to hospital. The patients should ideally be called one hour prior to the time of surgery, rather than “bolus admission system”, where all patients are called in the morning.
Most surgical procedures performed on children, especially the very young, are done using sedation or general anaesthesia. An experienced anaesthetist should perform a pre-operative check. We prefer to have the child receive sedation while with the parents to avoid separation anxiety. The use of local or regional blocks has been invaluable in minimizing the depth of anaesthesia and ensuring quick recovery as well as pain relief following surgery.
Following surgery, the child is observed in the recovery area till he is awake, and following assessment by the anaesthetist, can be discharged. A detailed set of instructions is handed over to the parents at the time of discharge.
Pain relief after surgery has been simplified with the use of effective analgesic suppositories, which are prescribed as appropriate.

Creating the Infrastructure
Whereas facilities, which will encourage day care, are existent in most private nursing homes, some major hospitals have still not recognized the value of day-care, and suitable spaces for recovery following surgery are not always available. In some institutions, cumbersome admission procedures are still required to be carried out. The provision of day-care beds, or the availability of economical day-care ‘package rates’, with a simplified registration protocol, would be welcome.
Also, at present, some insurance companies that reimburse patients for medical costs do not recognize the value of day care. There are several situations where overnight admission is recommended only to be able to forward a claim to the insurance company, even when there is no justification for the same on medical grounds. This appears self-defeating for an insurance company, where the cost of a hospital bed would have to be paid for.

TheFuture
Current U.K. day surgery involves admission, investigation or treatment, and discharge of suitable patients within one working day. In the USA the concept of ’23 hour stay’ day surgery has been developed, whereby patients are discharged following surgery within 24 hours of their admission. This will permit a much wider range of operations to be undertaken by allowing a longer period of monitored recovery.

CONCLUSION
In appropriate cases, day care surgery in children is safe and cost-effective, and should be utilized with greater frequency. Approximately 60% of surgeries performed by paediatric surgeons can and should be conducted in Day Care setting. Increased day surgery should help reduce the waiting period and improve access to inpatient beds. The selection of suitable patients and operation, proper parent’s education and good communication with general practitioners is the cornerstone of good day care surgical practice. The future day surgery is likely to include more intermediate operations, such as, laparoscopic surgeries which may require longer duration of post-operative stay.

REFERENCES
1. Nicoll JH. The Surgery of infancy. Br Med J 1909; 2 : 753.
2. Russell RH. The etiology and treatment of inguinal hernia in the young. Lancet 1899; 2 : 1353.
3. Herzfeld G. Hernia in infancy. Am J Surg 1939; 39 : 422.
4. Czerny V. Syudien zur radkalbehandlung der hernien. Wien med Wschr, 1877; 27 : 497.
5. Banks WM. Notes on radical cure of hernia- London, Harrison and Sons, 1884.
6. Ladd WE, Gross RE. Inguinal Hernia. In Abdominal surgery of Infancy and childhood. Philadelphia, W B Saunders, 1941.
7. Gross RE. Inguinal Hernia. In Surgery of Infancy and Childhood. Philadelphia, 1953.
8. Potts WJ , Riker WL, Lewis JE . Treatment of inguinal hernias in infants andchildren. ANN Surg 1959; 132 : 566.
9. Izant RJ. Non operative aspects of paediatric surgery. Report of 27 Ross pediatric research conference. Columbus, Ohio, 1957.
10. American Medical Association. Factors responsible for increasing costs of medical care. Chicago, American Medical Association, 1979.
11. Cloud DT, Reed WA, Ford JL. Surgi-center: A fresh concept in Outpatient Paediatric Surgery: J Paediatr Surgery 1972; 7 : 206.
12. Cloud DT. Outpatient paediatric Surgery. A Surgeons View. Intl Anaestheol Cli 1976; 14 : 130.
13. Reed RA, Ford JL. Development of an independent outpatient centre. Int Anaesthesiol Clin 1976; 14 : 130.
14. Cloud DT. Major ambulatory surgery of paediatric patient . In Davis JE.(Ed) Major Ambulatory Surgery, Baltimore Willams and Wilkins 1986.
15. Morse TS. Paediatric iutpatient surgery. J Paeiatr Surg1972; 7: 283.
16. Otherson HB, ClatworthyHW. Outpatient herniorraphy for infants. Am j Dis Child 1968; 116 : 78.
17. Presscott R J, Cuthbertome J, Fenwick N, et al. Economic aspect of day Care after operations for hernia and varicose veins. J Epidemiol Comm Health 1978; 32 : 222.
18. Kurth CD, Spitzer AR, Broemule AM. Post-operative apnoea in pre-term infants, anaesthesiology, 1987; 66 : 483-8.
19. Malone JH, Schwartz MZ, Tyson HRT. Out patient Inguinal Herniorraphy in pre-term infants-is it safe? J Pediatr Surg 1992; 27 : 203-8.
Further Reading:
- Commission on the provision of surgical services. Guidelines for DayCase Surgery. London: Royal College Of Surgeons of England,1992.
- NHS Management Executive. Report by the Day Surgery Task Force. London: HMSO, 1993.
- Schultz RC. Outpatient surgery from antiquity to present. In Schults RC (Ed.) Outpatient surgery. Chap 1, Philadelphia, Lea andFebiger, 1979.
- Davis JE (Ed) Major Ambulatory Surgery: Willams and Wilkins Baltimore 1986.
- Jarrett PEM. Day Case Surgery: Past and Future growth. Surgery 1997 ;15:4, 95.



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