Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice by Simon Paterson-Brown MBBS MPhil MS FRCS
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major advantages over inhalation agents; these include reduced PONV, early recovery and rapid control of the depth of anaesthesia, making it ideal for day case surgery. PONV after surgery is best prevented rather than treated, but is more likely if surgery lasts more than 1 hour or involves laparoscopy, dental procedures, squint surgery or correction of bat ears.
Adequate hydration reduces PONV and intravenous fluid should be administered during longer procedures. Intravenous fluids at a dose of 20 mL/kg significantly reduce the incidence of postoperative drowsiness and dizziness. 38
Pain management during anaesthesia is based on a concept of multimodal analgesia, which is a combination of two or more analgesic agents or analgesic techniques to minimise side-effects. A common strategy is to use an NSAID or short-acting opioid in combination with regional or local anaesthesia. The administration of stronger opiates such as morphine and pethidine at this stage is to be avoided as its longer-lasting effects may lead to unplanned overnight admission. Administration of analgesia in recovery and on the day ward before discharge should be given before ‘breakthrough’ pain occurs and is based on the accurate measurement of pain by the patients themselves.
Surgery
The safe, effective and efficient surgery required for a day case procedure demands the competence of a trained surgeon, a consultant or an experienced specialist registrar. In the past, the day surgery list of intermediate procedures was delegated to the most junior surgical trainee to perform without supervision. Not surprisingly, this led to prolonged operating times, patient cancellations, increased complications and an inevitable rise in the unplanned overnight admission rate. As surgical trainees may no longer work unsupervised, such poor-quality practices should be features of the past. Nevertheless, some consultant surgeons' attitudes towards day surgery remain lukewarm, mainly because many have never considered the importance of their role in the overall delivery of patient care and the need for them to be more actively involved in the process of care through the hospital system. A frequent excuse was that the surgery itself was mundane and lacked the technical challenge of complex major procedures. With the introduction of more major minimal access procedures into the field of day surgery, this excuse no longer holds true. Indeed, many day surgery experts would contend that any intermediate or major surgery performed on a day case basis is a true surgical challenge if morbidity is to be maintained at near zero levels.
Day surgery rates for specific procedures still vary between individual surgeons, between hospitals and even between regions. In November 2011, there was still a 17% variation in day case rates for inguinal hernia repair and varicose vein surgery between the best and the worst performing Strategic Health Authorities (SHAs) in England, whilst the rates for day case laparoscopic cholecystectomy in all SHAs ranged from 23% to 56%! 13 The reasons for such variations are complex and remain largely unexplained, but often reflect an inability to organise healthcare effectively and follow guidelines. 39 – 42
Whilst these variations were understandable in the development phase of day surgery, they become increasingly difficult to justify as we move to a genuine National Healthcare system, with equal access to treatment for all. A new generation of surgeons and anaesthetists who are more familiar with the skills and techniques necessary to provide high-quality day surgery should ensure that most of these extreme variations disappear over the next few years.
Surgical practice: controversies
Laparoscopic cholecystectomy: The day case rate for laparoscopic cholecystectomy in the UK is just under 40% and still shows large variations between surgeons, trusts and regions. 13 The reasons for this relate to fears about reactionary haemorrhage, delayed
Adequate hydration reduces PONV and intravenous fluid should be administered during longer procedures. Intravenous fluids at a dose of 20 mL/kg significantly reduce the incidence of postoperative drowsiness and dizziness. 38
Pain management during anaesthesia is based on a concept of multimodal analgesia, which is a combination of two or more analgesic agents or analgesic techniques to minimise side-effects. A common strategy is to use an NSAID or short-acting opioid in combination with regional or local anaesthesia. The administration of stronger opiates such as morphine and pethidine at this stage is to be avoided as its longer-lasting effects may lead to unplanned overnight admission. Administration of analgesia in recovery and on the day ward before discharge should be given before ‘breakthrough’ pain occurs and is based on the accurate measurement of pain by the patients themselves.
Surgery
The safe, effective and efficient surgery required for a day case procedure demands the competence of a trained surgeon, a consultant or an experienced specialist registrar. In the past, the day surgery list of intermediate procedures was delegated to the most junior surgical trainee to perform without supervision. Not surprisingly, this led to prolonged operating times, patient cancellations, increased complications and an inevitable rise in the unplanned overnight admission rate. As surgical trainees may no longer work unsupervised, such poor-quality practices should be features of the past. Nevertheless, some consultant surgeons' attitudes towards day surgery remain lukewarm, mainly because many have never considered the importance of their role in the overall delivery of patient care and the need for them to be more actively involved in the process of care through the hospital system. A frequent excuse was that the surgery itself was mundane and lacked the technical challenge of complex major procedures. With the introduction of more major minimal access procedures into the field of day surgery, this excuse no longer holds true. Indeed, many day surgery experts would contend that any intermediate or major surgery performed on a day case basis is a true surgical challenge if morbidity is to be maintained at near zero levels.
Day surgery rates for specific procedures still vary between individual surgeons, between hospitals and even between regions. In November 2011, there was still a 17% variation in day case rates for inguinal hernia repair and varicose vein surgery between the best and the worst performing Strategic Health Authorities (SHAs) in England, whilst the rates for day case laparoscopic cholecystectomy in all SHAs ranged from 23% to 56%! 13 The reasons for such variations are complex and remain largely unexplained, but often reflect an inability to organise healthcare effectively and follow guidelines. 39 – 42
Whilst these variations were understandable in the development phase of day surgery, they become increasingly difficult to justify as we move to a genuine National Healthcare system, with equal access to treatment for all. A new generation of surgeons and anaesthetists who are more familiar with the skills and techniques necessary to provide high-quality day surgery should ensure that most of these extreme variations disappear over the next few years.
Surgical practice: controversies
Laparoscopic cholecystectomy: The day case rate for laparoscopic cholecystectomy in the UK is just under 40% and still shows large variations between surgeons, trusts and regions. 13 The reasons for this relate to fears about reactionary haemorrhage, delayed
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