Medical science has made spectacular progress during the last quarter of century by undertaking a number of novel steps; daycare surgery is one of them.

Shorter hospitalisation has been recommended for minimising nosocomial infection, to cut down the expenditure and also to have a large patient turnover in the hospital or nursing homes. I have been exposed and practising short hospitalization for quite sometime now but did not have the chance of undertaking daycare surgery (hospitalization for less than 20 hours) for major procedures.

I have spent 37 years in PGI, a premier government institute with great rush of patients; the  trend over here has always been to investigate the patient completely, to get his  pre-anaesthesia check up carried out through  the out-patient department, and when everything is cleared for surgery, then to admit the patient and undertake surgery the very next day. An attempt was made to keep the post-operative hospitalisation to bare minimum. Daycare surgery procedures were restricted to minor operations undertaken under local anaesthesia only. There was natural hesitation to undertake daycare surgical procedures involving major operations or operations under general or spinal anaesthesia; the major reason for not opting for daycare surgery was lack of domiciliary medical support system, non-availability of satisfactory emergency medical care, unhygienic environment in the house, inability of the relations to understand and carry out basic medical jobs like proper administration of prescribed medicines, etc. We, therefore, always hesitated from such practices. The patient and his relations were probably more hesitant than the doctors.

I must also admit that the hesitation was also because of lack of commitment and initiative on our part for daycare procedures as all of us were full time government employees and also, on the part of the patient, as the bed rent was not substantial.

But, once I superannuated from PGI and went into practice, my perspective changed gradually. It is said that necessity is the mother of invention and same thing happened with me also. The patients that I started getting in my practice were obviously of better financial quality and more literate. The problem of unhygienic conditions, inability of administering the medicines as per instructions was no more there. But, I must admit that money was a major deciding factor, now my patient has to shell out a hefty sum of money for each day of his or her stay in the corporate hospital or the nursing home, ranging from Rs. 2000 to Rs. 6000 per day; and this prompted me to take initiative and I started having the hospitalization period much smaller than what I used to have in PGI. I also found out that majority of the patients would abide by my advice, after all the room rent pinches them more than me.

My Protocol: How I do it?
Cancer breast is a topic of my interest and I manage a reasonable number of cases. I started sending selected patients to their homes in less than 20 hours after surgery. The protocol is more or less fixed to support both the patient and the surgical team. The patient gets his needful investigations and pre-anaesthesia check up carried out through the outpatient.

The patient is given all the necessary instructions, is asked to have bath (including head bath) everyday for 3 to 5 days prior to surgery with an antiseptic soap, to take a laxative in the previous night, if need be. The patient takes her regular daily medicines (for hypertension, cardiac ailments, bronchial asthma, etc.) in the morning between 6 am and 7 am with a cup of tea or milk and then is completely off oral intake till the operation time. 40 mg of Pentaprazole, 0.5 mg of Alprazolam and any other medicine prescribed as premedication are also taken.

The patient reports to the hospital at about 11 in the morning, rests in the pre-operative room, intravenous infusion is started and the patient is shifted to the OT at about 1 pm. Operative procedure, modified radical mastectomy or breast conservation surgery, is carried out.

I use diathermy very liberally right after making epidermal skin incision by the scalpel and try to obtain very satisfactory haemostasis so that the blood loss is very less. Two drains are usually put in cases of MRM, one under the upper flap and the other one in the axilla, both brought out through separate stab wounds. The segmental mastectomy site is not drained, the dead space is filled up by rotating local breast tissue and the axilla is drained. I try to close the lower part of the axilla by stitching the axillary fascia to the chest wall and this decreases the axillary drainage.

Gentle handling of the tissue and good aseptic measures are meticulously followed. The entire surgical procedure takes about 70 to 90 minutes; patient is allowed to recover fully from anaesthesia before shifting to postoperative observation area. Profofol, Norcuron, Butrum, Midazolam, Pentaprazole, Perinorm are the few drugs that my anaesthetist colleague uses routinely during the operative procedure. I usually prefer an IV dose of third generation chephalosporin at the time of induction and another dose at about 10 pm at night.

The patient is shifted to her room after three or four hours stay in the postoperative area. The infusion drip is removed at about 8 pm, having received about 2.5 L of IV fluid in total, the cannula is retained. The patient is allowed oral fluids (water, tea, juice, soup) 4 to 5 hours after completion of surgery, can take a few biscuits or bread piece in the night for dinner. I have observed that the ability to eat and drink soon after surgery is moral boosting for the patient and also gives lot of confidence to the relations. The patient is propped up and encouraged to walk down to the toilet for emptying her urinary bladder. She is told to ask for Inj. Nimesulide or Tramodol in case of pain.

I usually visit my patient in the night at about 9 pm, the nurse informs me in detail about her condition early in the morning. My mobile phone is on round the clock, the patient is encouraged to contact me in case of need. In the morning the patient is made to sit up, brush her teeth, wash her face and have her regular breakfast. She is now on oral nimesulide for pain, and is advised to use her regular medicines for other associated medical problems. The patient is seen by me at about 9 am and discharged, advised to come to the clinic three days later for her first dressing; of course she is at liberty to call the surgeon round the call on the mobile.

Luckily, so far the protocol has worked well, no major problem has been noted, no patient had to rush back to the emergency; the only problem has been persistent ringing of my mobile phone with all the queries, right from diet to the dress, but I seem to have got used to these calls, may be I have started enjoying the phone calls.

I thought of starting the operation early in the morning, say at about 8 am, as I used to do in PGI, but my patients find it difficult to reach the hospital early in the morning, particularly if they are coming from outside Chandigarh. But soon I am going to try this on my local patients, discharging her in the evening and thus enabling her to enjoy sleep in her favourite bed and surroundings.

I feel that day care breast cancer surgery is feasible in our country and we should practice it more often, after all the best of the hospitals or nursing homes can not replace the sweet home.

USE OF INJECTIONS IN HEALTHCARE SETTINGS WORLDWIDE, 2000 : LITERATURE REVIEW AND REGIONAL ESTIMATES The combination of injection overuse and unsafe practices results in a major route of transmission for hepatitis B virus and hepatitis C virus. Other complications of unsafe injections include infection with HIV, abscesses, septicaemia, malaria and viral haemorrhagic fevers. BMJ, 2003; 327 : 1075.