Day Care Surgery

Dr.
Vivek Gharpure
Consultant pediatric surgeon
Children’s surgical hospital
Government medical college hospital
MIT hospital
Aurangabad
©Gharpure Hospital
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• Suitable
• Convenient
• Safe
• Economical
• State-of-art
©Gharpure Hospital
Rationale
Most procedures do not require any medical
treatment once the patient is conscious
For clean operations, one or two doses of
antibiotics enough
For operations not involving any body
cavity, observation not required
©Gharpure Hospital
• Conditions suitable
• Inguinal hernia (except preterm infant)
• Orchiopexy
• Circumcision
• Minor hypospadias
• Meatotomy/meatoplasty
• Cleft lip
©Gharpure Hospital
Conditions suitable(continued)
• Syndactyly/polydactyly
• Simple cystoscopy
• Upper gi endoscopy/variceal injection
• Colonoscopy/sigmoidoscopy
• CLN biopsy
• Shunt revision
©Gharpure Hospital
• Polypectomy
• Thiersch stitch for
prolapse
• Removal of foreign body
from git
©Gharpure Hospital
Patient criteria
• Otherwise normal
• Normal hemoglobin
• Not having respiratory infection
• Not requiring any additional treatment
• Should have faith in the surgeon
©Gharpure Hospital
Surgeon criteria
• Enough experience with day-care surgery
• Should be careful and have a delicate touch to
minimize blood loss/surgical trauma
• Should be able to manage a delayed recovery or
minor complication
• Patient should have faith in the surgeon
• Surgeon should have faith in day care surgery
©Gharpure Hospital
Hospital criteria
• Should have adequate and appropriate
equipment to administer general/regional
anesthesia to babies
• Should have resuscitation and monitoring
equipment
• Should have trained staff capable of taking
care of special needs of children
©Gharpure Hospital
Why convenient for surgeon/hospital
• Maximum revenue from the patient is
derived from the operative and OT charges
• Room charges are not adequate to cover the
services provided, particularly for large
hospitals
• More turnover can result in more revenue
and less expenditure
©Gharpure Hospital
Why convenient for surgeon/hospital
• Surgeons don’t have to take rounds on
patients who do not really require any
medical attention or medical decision
making and make chit-chat
• More time can be utilized for other serious
patients, public relations, marketing, study
etc
©Gharpure Hospital
Convenience for patient
• Less time spent away from home
• Less money spent on transport, food,
entertaining guests
• Less money spent on medicines purchased from
stores
• House need not be locked overnight
• Child does not fear the hospital, doctors and staff
©Gharpure Hospital
• Less antibiotics, less side effects, less
requirements for tonics and vitamins
• Less requirement for rest and time away
from work
• Less chances for getting hospital acquired
infection
©Gharpure Hospital
• No medicines to take at home
• Reduced incidence of nausea and
vomiting
• Reduced requirement for analgesics
©Gharpure Hospital
Methodology
• Patient has been seen as opd patient some
time prior to the procedure
• All investigations done on opd basis
• Actually no investigations are required for
simple opd procedures
• NO hemoglobin, NO urine, No other
investigation
©Gharpure Hospital
Methodology
• Patient examined one day prior to day of
operation and fitness assessed by surgeon
• All supplies arranged one day prior
• All equipment kept ready
• Anesthetist informed and time arranged
• Patient informed of the time
©Gharpure Hospital
Methodology
• Patient told to fast only 4 hours prior to
surgery time for liquids/2 hours for
water
• Patient reports 30 minutes before the
time fixed for operation
• Everything is ready for the patient
• When anesthetist arrives, patient
checked again
©Gharpure Hospital
Methodology
• Once anesthetist declares patient to be fit,
patient taken for surgery
• Surgery carried out under general or
regional anesthesia
• Cautery used to minimize blood loss and
handling
• Patient returned to ward/room after the
procedure
©Gharpure Hospital
Methodology
• One dose of antibiotic, usually cefotaxime or
ceftriaxone 50mg/kg administered as soon as IV
line is established.
• 12.5 mg diclofenac suppository inserted after the
procedure is over
• Iv fluids are continued till patient is conscious
• Oral feeds are started 4 hours after the
procedure
©Gharpure Hospital
Methodology
• Iv fluids administration- 20 ml RL/kg
given in the first 30 minutes
• Then the maintenance requirement
• Once patient passes urine, iv discontinued
• Soon after patient tolerates first feed of
water, feeds quickly increased to milk and
then semisolids
©Gharpure Hospital
• After patient has taken two/three feeds
and passed urine two/three times, he
can be discharged home
• At home, no antibiotics are given
• Analgesics are given on demand, oral
paracetamol is preferred
• Patient is called for first visit after 48
hours ©Gharpure Hospital
• In first visit, wound is not inspected if
patient does not have fever and does
not complain
• Dressing is palpated to check for
tenderness, induration, swelling
• If wound clean, dressing not opened
• Wound inspected if symptoms suggest
some problem ©Gharpure Hospital
• Patient called for second visit
on 7th day
• Subcuticular suture pulled
out and patient sent home
• Third visit after one month to
check for scar hypertrophy,
retained suture etc.
©Gharpure Hospital
Procedure (n) Stay in days
Herniotomy (243) 1
Orchiopexy (136) 1
Magpi( 107) 1
Chordee correction(98) 2
Ramstedt’s(78) 2
Appendicectomy(45) 2
Cleft lip(67) 2
©Gharpure Hospital
Anesthesia considerations
• Parents must understand instructions and
follow them explicitly
• Surgeon should be able to assess anesthesia
fitness and take decision
• Surgeon should be competent to adminster
fluid and electrolytes to children
©Gharpure Hospital
Objections
• Parents will not look after the child
properly
This does not occur. Baby does NOT
require any special care
• Wound infection may occur
In clean surgery, antibiotics are not
required. Even then we are giving one dose
prophylactic antibiotic. Wounds don’t get
infected ©Gharpure Hospital
• Post-operative nausea and vomiting
• If patient is not kept fasting for more
than 4 hours and is given feeds within
4 hours of the procedure, patients
rarely vomit.
• No patient has ever received anti-
emetic after surgery
©Gharpure Hospital
©Gharpure Hospital
Procedure (n) Complication

Herniotomy (243) 2 wound infections
Orchiopexy (136) 1 wound infection
Magpi( 107) None
Chordee 1 flap necrosis
correction(98)
Ramstedt’s(78) None
Appendicectomy(45) 1 stitch abscess
Cleft lip(67) One minor dehiscence
Conclusions
• Day care surgery feasible for many
conditions
• Day care surgery safe
• Day care surgery economical
• Day care surgery convenient
©Gharpure Hospital
Sas~ik`yaonaMtr baaLalaa
laagaNaaro ]pcaar¸
salaa[na [Mjaoxanacao
Daosa yaakirta Aamhalaa
dusaáyaa
baalaraogat&alaa
baaolaavaNyaacaI ikMvaa
baaLalaa dusaáyaa
©Gharpure Hospital
©Gharpure Hospital
Happy grandparents
©Gharpure Hospital
©Gharpure Hospital
Happy
Mrs.Surgeon
©Gharpure Hospital
Dr Vivek Gharpure
Consultant Pediatric surgeon
Children’s surgical hospital,
Aurangabad.
Government Medical College,
Aurangabad
Mithri,Aurangabad. ©Gharpure Hospital

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