Abstract
Retrospective analysis of 5 years of Day surgery cases from a single centre is presented. From June 2000 to May 2005, total of 3860 cases were performed; Major surgeries: 1114; Minor cases: 1415; Endoscopies: 1331. Most of the surgeries were done under Loco-regional anaesthesia or short GA.

Recommendations and Protocols suggested for a Day Care Surgery Centre were stringently followed.

Complications were encountered in 11 cases; most of these were seen in the initial two years.

Introduction
Our experience of day care surgery from a single centre has now undergone analysis of the past 5 years. This retrospective analysis is an update of the previous analysis, published in the earlier issue.¹

From June 2000 to May 2005, a total of 3860 cases were performed on a Day Care basis. The cases were divided into Major surgery, Minor surgery and Endoscopic procedures.

The Protocols of a Day Surgery Centre were used in case selection, patient preparation, discharge criteria’s and instructions.²

Cases were operated or performed under Loco-regional anaesthesia or Short GA.

There was a resultant reduction in the complications of post-procedure cases, re-enforcing the proposed protocols.

Material and Methods
Patients were selected and introduced to the proposed day surgery option during the first consultation. Patient information pamphlets were given to the patient and relatives, posters are displayed highlighting the advantages and disadvantages of day surgery in the reception for the waiting patients and relatives to see. Intra-operative and post-operative pictures of common surgical afflictions, which were operated at the centre, were shown to the patient with similar problem.

Patient preparation and instructions were carried out as per the protocols.

Patients were divided into two categories, Major and Minor surgery (Tables 1-3).

Anaesthesia
Most of the patients were operated under Loco-regional anaesthesia. Appendicectomies were performed under short General anaesthesia.

Regional blocks, namely: Pudendal, Ring, Inguinal, Cord and Field blocks were extensively used.

A combination of Lignocaine HCl 2% and Bupivacaine 0.5%, mixed in equal amounts were used. This anaesthetic solution is injected through a 1½ inch 26G or 27G needle.

At the time of injection of the local anaesthesia, our anaesthesiologist administers intravenous sedation in the form of Medazolam, Pentazocin and /or micro-dose of Ketamine, as per the requirement.

Since most of the surgeries can be completed in less than 1 hour, a safety margin of the local anaesthetic is well maintained, and can be repeated if surgery exceeds an hour.

Minor surgeries were done purely under local anaesthesia, where as, Endoscopies are normally performed under topical anaesthesia. Some patients require sedation, but a large portion of the patients were comfortable with just local anaesthesia.

Complication
Appendicectomy- 4 patients were hospitalised overnight due to excessive drowsiness and vomiting.

Haemorrhoidectomy- 2 patients had secondary bleeding. Both were managed conservatively. 1 patient was taken for examination under anaesthesia, but the bleeding has stopped by then.

Bilateral Hernioplasty- 1 patient was hospitalised, overnight for observation, due to excessive drowsiness.
4 patients went into urinary retention, were catheterised and discharged with the catheter.

Observation
When we compared the complications today, they are the same that were observed 3 years ago, when the number of procedures were much less. Therefore, the rate of complications has gone down.

Discussion
When we talk about day surgery, we include cases which are likely to be sent home on the same working day, after a short period of post-procedure observation.³

The proposed criteria’s for the functioning of a day care centre has been extensively utilised for case selection, as well as preparations. It involves detailing the advantages as well as disadvantages of day surgery to the patients and the referring physicians. “An empty bed in a hospital is like having a parked taxi with its meter running”, was a well thought of quote which sums up correctly, the cost effectiveness of a day surgery centre.

The loco-regional blocks are administered by the operating surgeon, which have been learnt over a period of time. But, an anaesthetist, with a minimum role of stand-by, is always available. There are times during the procedure, when, an apprehensive patient has required more than just sedation, causing to realise that an anaesthesiologist is necessary.

As the list of surgeries indicates, these are surgeries, which are not supra-major, do not require an institutional backing, but, these are surgeries which every general surgeon performs on a daily basis. In fact, these are what are called as ‘Bread and Butter’ daily surgical cases, which afflict more that 50% of patients attending your OPD/consulting room and would be willing to undergo surgery if it means reduced hospital stay and early return to work, with the added advantage of reducing costs.

The advantages of early recovery in familiar surrounding, leading to early return to normal life style, minimal disruption of patients as well as his family, lesser chance of acquiring hospital infections, and reduced cost, are well established and proven outcome of day care surgery.

Patient convenience, ‘single window’ concept, should be kept in mind while setting up a centre.

A little extra time spent during the first consultation with the patient and relatives have convinced many a reluctant patient, who would otherwise want medication for the treatment of inguinal hernia! When informed that this surgery can be performed without hospitalisation, the patient is more than willing to undergo the surgery.

A mentally prepared patient is half the post operative problems taken care off. Armed with the knowledge of expected complications and how to avoid them; if they do appear, and how to tackle them; makes a patient confident in himself and the system of surgical treatment.

As it has been written, ‘with a mother of average intelligence, assisted by advice from the hospital sister, the child fares better (at home) than in the hospital.’⁴

Conclusion
Advancement in day care surgery is attributed to the availability of better anaesthetic drugs and adaptation of newer techniques, better informed patients and willingness to trust the development in medical sciences, making it possible for day surgery to be called a ‘Technically superior’ method of giving surgical treatment to selected group of patients.

References

1. Day Care Surgery: A General Surgeon’s Perspective. T. Naresh Row, M. M. Begani, Niranjan Agarwal, Day Care Medicine-Surgery, Bombay Hospital Journal, Vol. 45, No. 2, April 2003; 206-10.
2. Protocols of a Day Surgery Centre, Author: T. Naresh Row, 2005.
3. The Day Surgery Operational Guide, A. Darzi, Dept. of Health August 2002, U.K.,1-28.
4. The Surgery of infancy, Nicoll JH. Br Med J 1909, 2:753.

*Consultant Surgeon, Abhishek Day Care Institute and Medical Research Centre, Mumbai 400 005. **Consultant Surgeon, Bombay Hospital and Medical Research Centre, Mumbai 400 020.