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DAY CARE SURGERY INCOLORECTAL DISEASES
M M Begani*, Niranjan Agarwal**
*Hon. Con. Surgon; **Hon. Asst. Cons. Surgeon, Bombay Hospital, Mumbai 400 020.
There are certain surgical procedures that owing to their magnitude should always be done in the hospital. There are many minor procedures that can routinely be done in the surgeon's office, emergency room or the OPD under local anaesthesia with immediate discharge of the patient. Between these two ends of the surgical spectrum are a large number of procedures that in the appropriate patients and under proper circumstances and conditions can be done as major ambulatory surgery (MAS). It is the surgeon's obligation and responsibility in concurrence with the patient to make this decision. Nearly 60% of the surgical procedures are expected to be performed in an ambulatory setting. Major ambulatory surgery has thus become an accepted modality of delivery of surgical care, wherein all the participants (Patient, Dr., Management) gets benefitted and hence it has steadily grown in availability and utilization.Patient selection for day care surgery
In general terms day care surgery (DCS) consists of procedures in which the body cavity is not entered and that can be accomplished satisfactorily in one hour or less, on an individual who is otherwise healthy. The following factors are considered:
1.Physiological factorsa. Age : premature < 6 months age are not accepted for DCS.
b. Body Mass Index : > 34 not acceptable for DCS.
c. American Society of Anaesthesiologists (ASA) : I, II, and III (Only well controlled asthmatic, hypertension, diabetes mellitus on insulin) are considered for day care surgery
2.Psychological factors
a. Patients acceptance towards the concept ofDCS
b. Truly psychiatric patients are preferred foran In-patient surgery.
c. Mental retardation is a constraindication forDCS.
3.Social factors
a. Distance between patients residence and theDCS centre should be less than one hourjourney.
b. Easy access to toilet, telephone, transport athome.
c. Presence of an adult responsible attendantto look after at home.
d. Financial obligation to be met.
Contraindication for DCS
1.Severe mental retardation.
2.Highly infectious diseases
3.URTI and febrile state > 38oC
4.Shock and trauma patient.
5.Patient requiring extensive invasive monitoring.
6.American society of anaesthetist IV, V and III with uncontrolled medical problem.
7. Premature < 6 months age.
8.BMI > 34 and obese.
9.Long distance from home.
10.Lack of responsible adult relative, and proper toilet, telephone, and transport facility.
Advantages of day care surgery
1.Minimal changes in life style of the patient.
2.Psychological benefits of eliminating prolonged hospital stay especially for the children.
3.Patient faces less anxiety as he is not mixed with other serious patients.
4.Cost is curtailed without sacrifice of prerequisite.
5.Decrease risk of nosocomial infection and over all post operative morbidity.
6.Early return to physical activity and work.
7.Avoids complications related to general and regional anaesthesia as local anaesthesia is used maximally.
8.Beneficial effect on in-patient waiting lists and hospital beds.
Disadvantages
1.Non adherence to pre-op instructions by patient.
2.Lack of transportation to and from the day care surgery centre.
3.Lack of adult attendant at home.
4.Absence of immediately available supportive and resuscitative back up.
Criteria to be met on discharge
1.Stable vital parameters.
2.Alert oriented.
3.Pain free.
4.Mobile - goes to bathroom.
5.Tolerate oral feeds.
6.Adult relative present.
Until recently surgeons were hesitant to perform anal and rectal procedures in an ambulatory setting because of fear of post operative pain and voiding (Micturition / urination) difficulties by males. This attitude has slowly changed due to better control of pain by long acting local anaesthetic drugs and the realisation that catheterization be done if the need be and discharged. Removal of catheter later on in the surgeon's office does not pose much problem. Due to increase in experience and confidence many patients with anorectal diseases are now enjoying the benefits of MAS (Major ambulatory surgery). More than 90% of anorectal surgeries can be done successfully on an ambulatory basis with greater convenience and economy without sacrificing of comfort or safety.Anorectal surgeries routinely done in DCS
1.Colonoscopy / sigmoidoscopy with or without biopsy.
2.Incision and drainage of perianal and ischiorectal abscesses (except for toxic patient).
3.Anal stretching.
4.Fissurectomy, lateral sphincterotomy for anal fissures.
5.Fistulotomy / fistulectomy for fistula in ano.
6.Excision / banding / injection sclerotherapy of haemorrhoids.
7.Excision of rectal polyps.
8.Surgery for pilonidal sinus.
9.Thiersch wiring for rectal prolapse.
10.Cauterization / excision of condylomata acuminata.
In our unit majority of cases pertaining to the anorectal area are successfully being performed on a day care basis. Our preference is for local anaesthesia with IV sedation for selected cases (except abscess) as against general or regional anaesthesia used by the majority of the surgeons. Local anaesthesia is safe and effective with decrease morbidity, mortality and cost as well as highly useful in smaller setup.Our policy
1.Patients are worked up as for GA (Safety reason)
2.Generally alprazolam 0.5 mg is used to allay anxiety and for sedation on the night prior to surgery, 3 tabs of dulcolax orally to evacuate the bowel.
3.Patients are informed prior to surgery about the type of anaesthesia and the amount of pain expected, and the post operative benefits. This makes our job easier by ensuring full co-operation from the well motivated patient.
4.Anaesthetist is always present for IV sedation and patient monitoring.
5.Intravenous sedation used.
1. Pethidine 50 mg or fortwin 30 mg.
2. Fulsed 2 mg or calmpose 10 mg.
3. Ketamin 25 to 50 mg.
6.Lithotomy position is preferred (except for pilonidal sinus where prone position is used) or (Jack knife)
7.Local anaesthetic agents used
a) xylocaine 2% 30 ml with or without adrenaline as per the patient's cardiovascular condition.
b) sensorcaine 0.5% 20 ml.
The above solutions are mixed and 10 ml D/W or N/S is added to it to make a 1% xylocaine solution.On an average for a person weighing more than 50 kg around 20 to 30 ml of the above solution is used.
Techniques
1. Ring block : For fresh cases (not operated previously)
a.Using 26 number needle subdermal wheals are raised at the 4 points - 12, 3, 6, 9 O'clock position.
b.The deeper portion at these points are infiltrated next using 1-2 ml of the solution.
c.Using a 25 number long (1 1/2") inch needle which is slightly bent at its point of origin manually for making the infiltration easier in a circular manner, 3-4 ml of the solution is infiltrated in the intermediate areas of the circle, piercing only at the previous anaesthetized points.
d.Compression is applied with pack of gauze or a surgical mop at the anal verge for 5 minutes to allow the local anaesthesia action to start and to prevent haematoms formation at puncture site.
e.This blocks the sphincter and the lower anorectal area excellently allowing all procedure to be carried out successfully without difficulty.
f.Gradual anal stretching is upto four fingers. The planned surgery is carried out. Haemostasis is achieved on table by cauterzation or suture.
g.Post procedural we put around 20 ml of veseline (and a diclofenac suppositary) in the rectum to achieve pain relief and a pain less motion post operatively which is generally otherwise painful.
h.Patient is dressed with T-bandage gamjee compression after surgery. Local dressing with povidone iodine soaked guage and a gamgee pad over it held in position by bandage is given. No intraluminal packs are used.
This helps in decreasing the pain and easy voiding in post operative period.
i.Patient are fed after three hours and discharged by evening on assuring the discharge criteria mentioned above and patient has passed urine.
2. Pudendal block : It is used for recurrent cases or when there is excessive fibrosis around the anal verge or in chronically infected cases.
Inferior haemorrhoidal nerve is blocked using the above solution.
a.With a 26 no. needle subdermal wheal is raised on either side of the anal verge at the mid point of the line joining the anal verge to anus to the posterior border of ischial tuberosity.b.Using a 1 and 1/2 inch long 25 no. needle, this point is pierced perpendicular to the skin and the needle inserted deep and laterally till it touches the medial side of ischial tuberosity. The solution is then injected while withdrawing the needle and surrounding area is infiltrated similarly using a to and fro movement on anteriorly centre and posteriorly both the sides. This effectively blocks the inferior haemorrhoidal nerve and the procedure is then carried out from point d to i as described above.
Complications
1.Toxic reactions to the local anaesthetic agent.
2.Rectal puncture
3.Temporary ecchymosis of perineum and buttocks.
4.Haematoma
5.Local infection
6.Giddiness, syncope, bradycardia, nausea, vomiting, bleeding, pain, urinary retention and partial incontinence of flatus and faeces are early complications
7.Anal stenosis, recurrence and mucus discharge are late complications.
Advantages
1.Avoids complication of general anaesthesia / regional anaesthesia
2.Suitable for high risk cases which are contra indicated for general or regional anaesthesia.
3.Faster post operative recovery with lesser starvation, IV medication and hospital stay.
4.Cost benefits.
5.Less blood loss.
Disadvantages
1.Block failures.
2.Wearing off actions especially if the procedure is prolonged.
3.Awareness of patient.
4.Toxicity and other complications.
5.Patient is uncomfortable in lithotomy position without anaesthesia.
We have performed more than 5000 cases of anorectal diseases on a DCS from 1980 to 2000.
The percentage of different surgeries has been as follows :
Piles 32%
Fissure 18%
Fistula 16%
Abscess 11%
Pilonidal sinus 4%
Others 19%Skin lesion
Anal stenosis and stricture
Warts
Adenoma
Polyps Lower g.i. endoscopiesTwelve patient overstayed because of the complications they suffered. These were as follows :
a) Arrhythmia due to local anaesthetic agent - 1b) Syncope - 1
c) Urine retention - 5
d) Haemorrhage - 1
e) Extension of operative field (Branched Fistula) - 2
f) Fever - 2
CONCLUSION
Major ambulatory surgery has become an acceptable form of delivery of surgical care which helps not only in controlling the escalating cost of health care, but also promote faster recovery and return to work with minimal disruption of patient's life style. Though MAS is becoming increasingly popular, it however requires specific facilities and organisation for careful pre operative patient selection and delivery by experienced staff specifically conversant with the management of post operative pain and early discharge from the hospital. Proper patient education and motivation, pre operative, intra operative and detailed instruction on discharge verbal and written (As you go home) and follow up would go a long way on promoting day care surgery.
REFERENCES
1.Goldsmith JC. Personal communication. 1986.
2.James Davis, Kenneth Sugiok. SCNA - MAS 1987.
3.Berry FA. Pre operative assessment and general management of out patients. Int Aneaesthesiol Clin 1982; 20 : 3-10.
4.Med well SJ, Friend WG. Out patient anorectal surgery. Dis Colon Rectum 1979; 22 : 480-2.
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