Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice by Simon Paterson-Brown MBBS MPhil MS FRCS Page A

haemorrhage and bile leak. Reactionary haemorrhage occurs within 4–6 hours after surgery and can be addressed within the ordinary working day if the surgery is performed before noon. Delayed haemorrhage usually occurs 3–4 days after cholecystectomy and even if the patient had undergone their operation as an inpatient, they would still have gone home before the secondary haemorrhage was apparent. Bile leaks rarely become apparent before 48 hours after surgery: accessory duct injury is often insidious, diathermy injury to the biliary tree may take days to leak and cystic duct stump leakage likewise. Again, if the patient had undergone inpatient surgery the likelihood is that they would already have been discharged home. It is therefore more important to warn these patients of possible delayed complications and that they should seek medical review in the first few days after discharge if alarm symptoms such as abdominal pain, nausea and vomiting occur. The NHS Institute published a clinical pathway in 2007 which noted that 70% of laparoscopic cholecystectomies could be safely performed as day cases 40 and this target has been recommended to NHS commissioners as part of the 18-week programme. 43
    Successful day case laparoscopic cholecystectomy relies on rigorous patient selection, accepting only well-motivated and non-obese patients, and attention to detailed surgical technique. Patients require approximately 6 hours of recovery time and the procedure is best performed early in the operating day.
     
    Age greater than 50 and ASA class II and III are poor prognostic indicators. 44 , 45
    Good operative technique is also relevant when creating the pneumoperitoneum, as carbon dioxide inadvertently placed in the extraperitoneal space can cause considerable discomfort. Shoulder tip pain from diaphragmatic irritation has been related to the size of the gas bubble under the diaphragm 46 and attempts should therefore be made to expel as much gas as possible at the end of the procedure. Blood in the peritoneal cavity is an irritant, and liver bed haemostasis and peritoneal lavage before exiting the abdomen are worthwhile. While much of the postoperative pain in laparoscopic cholecystectomy is deep in nature, laparoscopy port sites should always be infiltrated with a long-acting local anaesthetic (such as bupivacaine). There appears to be little difference between infiltration at the beginning or the end of the procedure. 47
    Prostatectomy: For benign prostatic disease, the current national day case rate for laser ablation is 10% and for transurethral resection is just over 1%, although the rates are 30% in London and 10% in south central England. 13 Patients requiring prostatectomy tend to be older and less fit and many have previously been excluded from day surgery by their comorbidity. Conventional transurethral resection of the prostate (TURP) can be performed as a day case but postoperative haemorrhage remains a problem. Over the last decade, laser prostatectomy day case programmes have been developed, 48 , 49 with the patients discharged with a catheter in situ, returning to the day unit approximately 1 week later for trial without catheter. Some units now perform over 90% of prostatectomies as day cases. 50
    Head and neck:
     
    In the UK, 6% of tonsillectomies are performed on a day case basis due to worries about reactionary haemorrhage. This risk is small and in a series of 668 adults and children undergoing day case tonsillectomy in Salisbury, the reactionary haemorrhage rate was 0.3%, each occurring within the first 6–8 hours after the operation while the patient was still on the day unit. 51

    Secondary haemorrhage occurs in approximately 1% of post-tonsillectomy patients and occurs several days after discharge, but may cause rapid airway obstruction at home with fatal consequences. The Salisbury Unit has a high readmission rate of 6% that reflects their policy of readmitting even minor bleeds for 24 hours in case they