Historical Background and Review of Literature
One of the first and most extensive use of
laparoscopy was seen in gynaecology. Laparoscopy was used for diagnostic purpose under short GA and early recovery of the patients afforded an early discharge. This started a trend of its application in day care surgery. Once the safety and efficacy was established, operative procedures were performed more frequently. Over a period of time, laparoscopic hysterectomies as day care, in the hands of experts, have been reported in the world literature.1
The beginning of 20th century has seen a revolution in the field of surgical speciality encompassing all the specialities under one canopy, that of laparoscopic surgery. A much older concept of surgery, again, involving most of the surgical branches, is Ambulatory or Day Care surgery. The benefits of both these modalities of surgical treatment have proved their validity and stood the test of time, resulting in tremendous advantages to the patient population. The combination of laparoscopy and day surgery far exceeds or supersedes any reservations we may have. This article is a brief insight in to day care laparoscopic surgery, which is yet to realise its full potential in India.
Anaesthesia forms the main stay of day surgery especially for laparoscopic day surgery. Pre-anaesthetic preparations with NSAIDs and sedative/anxiolytics administered the day before the procedure helps in the intra-operative as well as the post-procedure recovery. The development of better anaesthetic agents has given rise to newer terminologies like ‘sedoanalgesia’.2 The availability and extensive use of drugs like Propofol, Acuronium, etc., the ultra short acting anaesthetic agents, have boosted post-procedure recovery, making day surgery possible. The common criteria for Day surgery are detailed in the “Protocols of a Day Care Centre”, a booklet offering insight into the setting up and running of a Day surgery centre, helpful in increasing efficiency of patient management.3
- Previous abdominal surgeries, especially laparotomies, are a relative contraindication to Laparoscopic surgery. Hassan’s open insertion of primary port, is a method of choice for safe placement of ports in the previously operated cases. The primary port should be placed away from the previous scar or area where adhesions are expected.4
- Body Mass Index : (expressed as: weight in kilograms divided by the height in meter square) of more that 35 kg/m2, is a general contraindication for day care laparoscopic surgery. The obvious technical difficulties during surgery as well as anaesthesia can increase the morbidity.
- Patients free from any medical disease (ASA I and II) are suitable candidates for laparoscopic day surgery. In selected cases, well controlled ASA III can be selected for day surgery.
- Motivating a patient who is prepared to ‘get up and go’ do very well in the day surgery set-up.
- Specific procedures where preoperative or postoperative prolonged care is required cannot be performed as day care.
Patients should be completely worked-up including medical fitness, where necessary. Investigations include Haemogram, blood Sugar, HIV, HBsAg, urine, stool, X-ray chest, ECG; USG, liver and kidney function, 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).
- Diagnostic, routine, post trauma
- Hernia repair
- Biopsy: liver, lymph nodes, etc
- Diagnostic, dye studies
- Tubal ligation
- Ovarian cyst excision
- Tubal cannulation
- Ovarian drilling
- Myomectomies for small fibroids
- Endometriosis ablation
- Simple oophorectomies
- Tuboplasty, fimbrioplasty
||Infertility: Operative Laparoscopic work.
- Kidney biopsy
- Renal cyst decortication
- Varicose vein ligation
- Lumbar sympathectomy
- Simple nephrectomy
- Injury to bowel and blood vessel during the introduction of trocar.
- Anaesthesia related complications, requiring re-admission.
- Complications related to pneumo-peritoneum, referred pain to the shoulder.
- Abscess formation at the operated site and port site.
- Team approach, involvement of Family Physician or referring doctor in the post-operative care.
- Patient should fulfil the discharge criteria: no pain, no giddiness, no vomiting, able to walk without support, presence of relatives, explanation of complications and its management, contact numbers of the team of doctors and doctors near the patient's residence, etc. help reduction of complications.
The economical implications of day surgery are tremendous, a study on the socio-economical aspect of day surgery in a public hospital set-up, in India, was an eye opener as to the implications of savings to the government exchequer.7 It has shown the cost of major day surgical procedures to be one third the cost of admitted patients.
Similarly, its application to laparoscopic surgery, in DCLC (Day Care Laparoscopic Cholecystectomy), as shown by a group in an exhaustive study in India, has indicated, along with various observations, favourable economic solution.8
Laparoscopic day surgery is a viable option in expert hands.
- Erian J, El-Toukhy T, Chandakas S, Theodoridis T, Hill N. One hundred cases of laparoscopic subtotal hysterectomy using the PK and Lap Loop systems. J Minim Invasive Gynecol 2005; 12 (4) : 365-9.
- Snyder, Douglas S. Day-case anaesthesia and sedation. Maryland Anesth 1995; 82 (1) : 324.
- Row TN. Protocols of a day surgery centre. The Indian Association of Day Surgery April, 2005.
- McWhinnie D, Ellams J, Cahill J, Smith I. Day case laparoscopic cholecystectomy. A British Association of Day Surgery Handbook, Published: December 2004.
- Row TN, Begani MM. Day care surgery in India. J One Day Surg 2003; 12 (4) : 53-4.
- Row TN, Begani MM. Day care medicine and surgery. Bom Hosp J 2003; 45 (2) : 183-7.
- Bapat RD, Kantharia CV. Day care surgery-socioeconomic need of the hour. Bom Hosp J 2003; 45 (2) : 191-3.
- Bal S, Reddy LGS, Parshad R, et al. Feasibility and safety of day care laparoscopic cholecystectomy in a developing country. Postgrad Med J 2003; 79 : 284-8.
CARDIAC IMPAIRMENT OR HEART FAILURE?
Everybody can have a bit if they try hard enough, by physical exertion or even by emotional shock. But, apart from transient induced cardiac overload, the term can be used to mean anything from asymptomatic systolic dysfunction to imminent death from pulmonary oedema. Because of widely varying definitions, the epidemiology of heart failure can become almost uninterpretable.
The recent increase in interest in heart failure bagan with interventional studies among highly selected patients. They were mainly men aged 60-65 on average, with a history of myocardial infarction or cardiomyopathy and a left systolic ejection fraction of less than 30-35% as measured by cardiac catheterisation or radionuclide ventriculography. After initial success in treating such patients with angiotensin converting enzyme inhibitors, a series of other drugs were tried, usually by addition and using similar selection criteria.
To identify patients with heart failure who correspond to the group for which we have an evidence base, clinicians and service providers have focused on improving access to echocardiography. But echocardiography alone cannot diagnose heart failure : it is not the "gold standard". Although it is relatively cheap and accessible, several other methods are more accurate. But heart failure remains a clinical diagnosis, and functional status and prognosis bear little relation to the ejection fraction alone. In a recent European study researchers, like many clinicians, used an ejection fraction of 50% to define "systolic dysfunction". They found no difference in 10 year survival among patients with ejection fractions above and below this level. Similar outcomes have also been reported in hospital patients in the UK, using ejection fraction of 40% as the cut-off point.
Because heart failure is a continuum, its definition should be based on the best marker for prognosis. There is little doubt that the best single marker is the level of the cardiac hormone. B-type natriuretic peptide, in blood : measured on a single occasion, it outperforms all other tests.
Richard Lehman, Jenny Doust, BMJ, 2005; 331 : 415-16.