Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice by Simon Paterson-Brown MBBS MPhil MS FRCS Page B
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herald a more major bleed.
Similarly, parathyroid surgery has not been deemed suitable for day case surgery because of the risk of haemorrhage and hypocalcaemia. Nevertheless, McLaren and colleagues have demonstrated high and safe day surgery rates in patients with positive preoperative localisation. 52
Bariatric and other surgery: Bariatric or weight loss surgery is increasingly performed in the UK, as a result of the growing number of morbidly obese in the population who fail to respond to dietary methods or exercise. Obesity is a risk factor for any surgery, 17 but shorter, minimal access procedures such as laparoscopic gastric banding have been performed successfully as day case procedures, 53 the limiting criteria being the 150-kg weight limit of most operating trolleys. Of greater significance is perhaps the implied message that BMI should no longer be seen as a limiting factor in the delivery of day surgery generally.
Other areas of surgery are developing fast-track or short-stay admissions as a preferred clinical pathway for their patients, for the same reasons surgeons applied day surgery techniques 30 years ago for hernia and paediatric surgery: when delivered to a high standard, safely and efficiently, patients and providers benefit. Kehlet described his experience in developing enhanced recovery programmes in colorectal surgery a decade ago and the principles have been extended to broader aspects of surgery. 54 , 55 Clinicians using techniques as diverse as abdominoplasty, colorectal cancer surgery, thoracic surgery and even endovascular aortic grafting are now using these techniques to shorten lengths of stay while enhancing patient care. 56 – 59
Recovery
Upon completion of anaesthesia at the end of a surgical procedure, the patient is transferred to the operating theatre recovery area known as ‘first-stage recovery’. Formerly, patients remained here for a predetermined period, commonly 30 or 60 minutes. However, the development of short-acting anaesthetic agents, the introduction of minimally invasive surgical techniques and individual patient variability meant that patients were often ready for transfer to ‘second-stage recovery’ before their predetermined time. Therefore, ‘time-based recovery’ is no longer necessary and has in many units been superseded by ‘criteria-based recovery’, where discharge is determined by the observations of stable vital signs, return of protective reflexes and the ability to obey commands. 60 ‘Second-stage recovery’ occurs back in the ward or trolley area of the day unit itself, where patients recover sufficiently to allow safe discharge home. Certain patients may be suitable for direct transfer to second-stage recovery from the operating theatre itself ( Fig. 3.3 ) and include patients who have received local or regional anaesthesia with or without minimal sedation.
Figure 3.3 Staged patient recovery.
Postoperative instructions and discharge
Before leaving the day unit, patients require specific information regarding their medication, wound care and when they are able to bath or shower, arrangements for suture removal or dressing renewal, when they can resume normal activities and arrangements for follow-up (if appropriate). It is also important to offer a contact telephone number for emergency purposes on the night of discharge. In addition, patients must be clearly instructed not to drive a motor vehicle for at least 24 hours. 61 Appropriate preoperative information may also have a beneficial effect on return to work after surgery. 62
The most common reason for a patient visiting their general practitioner after day surgery is to obtain certification for time off work. The second commonest reason, usually in an unplanned manner, relates to worries about their wound. After discharge, many day surgery units therefore offer outreach or telephone follow-up for their patients 24 hours later. This can be an effective evaluation tool, where any identified
Similarly, parathyroid surgery has not been deemed suitable for day case surgery because of the risk of haemorrhage and hypocalcaemia. Nevertheless, McLaren and colleagues have demonstrated high and safe day surgery rates in patients with positive preoperative localisation. 52
Bariatric and other surgery: Bariatric or weight loss surgery is increasingly performed in the UK, as a result of the growing number of morbidly obese in the population who fail to respond to dietary methods or exercise. Obesity is a risk factor for any surgery, 17 but shorter, minimal access procedures such as laparoscopic gastric banding have been performed successfully as day case procedures, 53 the limiting criteria being the 150-kg weight limit of most operating trolleys. Of greater significance is perhaps the implied message that BMI should no longer be seen as a limiting factor in the delivery of day surgery generally.
Other areas of surgery are developing fast-track or short-stay admissions as a preferred clinical pathway for their patients, for the same reasons surgeons applied day surgery techniques 30 years ago for hernia and paediatric surgery: when delivered to a high standard, safely and efficiently, patients and providers benefit. Kehlet described his experience in developing enhanced recovery programmes in colorectal surgery a decade ago and the principles have been extended to broader aspects of surgery. 54 , 55 Clinicians using techniques as diverse as abdominoplasty, colorectal cancer surgery, thoracic surgery and even endovascular aortic grafting are now using these techniques to shorten lengths of stay while enhancing patient care. 56 – 59
Recovery
Upon completion of anaesthesia at the end of a surgical procedure, the patient is transferred to the operating theatre recovery area known as ‘first-stage recovery’. Formerly, patients remained here for a predetermined period, commonly 30 or 60 minutes. However, the development of short-acting anaesthetic agents, the introduction of minimally invasive surgical techniques and individual patient variability meant that patients were often ready for transfer to ‘second-stage recovery’ before their predetermined time. Therefore, ‘time-based recovery’ is no longer necessary and has in many units been superseded by ‘criteria-based recovery’, where discharge is determined by the observations of stable vital signs, return of protective reflexes and the ability to obey commands. 60 ‘Second-stage recovery’ occurs back in the ward or trolley area of the day unit itself, where patients recover sufficiently to allow safe discharge home. Certain patients may be suitable for direct transfer to second-stage recovery from the operating theatre itself ( Fig. 3.3 ) and include patients who have received local or regional anaesthesia with or without minimal sedation.
Figure 3.3 Staged patient recovery.
Postoperative instructions and discharge
Before leaving the day unit, patients require specific information regarding their medication, wound care and when they are able to bath or shower, arrangements for suture removal or dressing renewal, when they can resume normal activities and arrangements for follow-up (if appropriate). It is also important to offer a contact telephone number for emergency purposes on the night of discharge. In addition, patients must be clearly instructed not to drive a motor vehicle for at least 24 hours. 61 Appropriate preoperative information may also have a beneficial effect on return to work after surgery. 62
The most common reason for a patient visiting their general practitioner after day surgery is to obtain certification for time off work. The second commonest reason, usually in an unplanned manner, relates to worries about their wound. After discharge, many day surgery units therefore offer outreach or telephone follow-up for their patients 24 hours later. This can be an effective evaluation tool, where any identified
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