The effectiveness of benzodiazepines and narcotics in outpatient surgery

In a prospective study of 211 outpatients undergoing cosmetic surgical procedures under local anesthesia supplemented with intravenous diazepam and morphine, patient pain response to the local anesthetic infiltration was graded and the recall of the operative experience was assessed. One hundred and fifty-five patients (73%) had either no pain response or a mild response, 41 (19%) had a moderate response, and 15 (7%) had a severe response. One hundred and eighty-seven patients (88%) had total amnesia for the local anesthetic infiltration and the operative procedure, and 183 (87%) could not recall pain, but had recall of events during surgery. There were no untoward drug reactions nor episodes of cardiorespiratory depression. We conclude that intravenous diazepam with or without intravenous morphine following triazolam, morphine, and premethazine premedication is a safe and effective regimen, for outpatient surgery.     

The use of drains for outpatient orthopaedic surgeries: Safety and efficacy

While drains have been routinely used in orthopaedic surgery for postoperative wound drainage following inpatient surgical procedures, there are no published reports on the safety or efficacy of drains for outpatient orthopaedic surgeries. This review reports our experience between July 1995 and January 1996 with the use of drains for 35 patients having outpatient orthopaedic surgery. Consequences of drain usage were determined by medical chart review and a follow-up telephone survey in which patients were asked a series of questions regarding the drains used for their operation. None of the patients had an infection or any other medical problem as a result of drain usage and there were no problems with wound healing. Patients were quite capable of managing and removing their own drains. We conclude that drains are effective and can be used safely for outpatient orthopaedic surgical procedures.     

Comparison of Outpatient Laparoscopic Cholecystectomy in a Private Nonteaching Hospital versus a Private Teaching Community Hospital

The development of laparoscopic cholecystectomy has allowed the introduction of outpatient surgery for biliary tract disease. However, there appears to be a wide variation of the interpretation of “outpatient surgery,” ranging from discharge the same day to keeping patients for overnight observation. We prospectively reviewed the last 50 cholecystectomies performed at Spartanburg Regional Medical Center, a private teaching institution, and Upstate Carolina Medical Center, a private nonteaching hospital.All cholecystectomies were performed by board certified surgeons or surgical residents under the supervision of board certified surgeons. Spartanburg Regional Medical Center''s standard was 23-hour observation with 9 patients (18%) being discharged home the day of surgery. Upstate Carolina Medical Center''s standard was discharge home (usually 4-8 hours after completion of the procedure) with 39 patients (78%) discharged the same day. No patient discharged the same day presented back with any significant complication. Comorbid disease, biliary pancreatitis, ascending cholangitis, gangrenous gallbladder, extreme age and living conditions and conversion to open were factors considered for admission. Intra-operative difficulty such as oozing, excessive adhesiolysis, postoperative nausea, vomiting or pain control were also indications for overnight admissions.The extra 15 to 19 hours for routine observation did not change any treatment for any of the 41 patients and resulted in additional cost to the hospital of approximately $15,000.We conclude that same day, outpatient laparoscopic cholecystectomy can be done safely with discharge home 4 to 8 hours postoperative without significant morbidity in selective patients.     

Reduction mammaplasty: A comparison of outpatient and inpatient procedures

A review of the procedure, postoperative outcome, and expense of outpatient inferior pedicle reduction mammaplasty was compared with inpatient hospital treatment. Twenty outpatient procedures were compared with an equal number of inpatient procedures. Medical and social backgrounds of the two patient populations were similar. The findings indicate that bilateral breast reduction can be performed safely and cost-effectively as an outpatient procedure.     

Surgical treatment of breast lesions at a Day Centre: Experience of the European Institute of Oncology

Breast cancer is the commonest malignancy in women worldwide. The reduced aggressiveness of breast cancer surgery has made it possible treat patients in the day surgery setting. The European Institute of Oncology, Milan, opened its new Day Center in May 2010. From May 2010 to December 2014, 17,087 patients with breast conditions were treated by the Institute's Division of Senology, 4132 (24.2%) of these in the day surgery setting, including malignant and benign conditions; 204 (4.9%) were not discharged on the day of surgery, being converted to inpatients; five (0.1%) patients returned to hospital for persistent hematoma.Our experience of performing breast cancer surgery in the day surgery setting is in line that of the literature. It is safe, but requires a well-organized unit and multidisciplinary medical team to function smoothly, with much attention paid to patient comfort and education, so as to ensure maximum patient acceptance and satisfaction.     

Análisis de satisfacción y resultados quirúrgicos de un programa de cirugía mayor ambulatoria para el implante de prótesis de pene

Introduction and objectivePenile prosthesis (PP) surgery is performed in many institutions as an inpatient procedure. We have recently initiated a major ambulatory surgery (MAS) program, thus reducing the hospital stay.The objective of this study was to assess the feasibility, complications and satisfaction of the implantation of outpatient surgery PP program in our hospital.Material and methodsRetrospective observational study evaluating the results and satisfaction of PP implanted as an outpatient procedure in Bellvitge University Hospital during 2018.ResultsDuring 2018 we implanted 49 PP: 27 (55%) inpatient surgeries vs. 22 (45%) outpatient surgeries. Of these 22, 2 (9%) were second implants. All patients underwent both general anesthesia and crural, proximal dorsal nerve and transversus abdominis plane block (TAP). Complication rates between inpatient and outpatient procedures were similar, 2 (7%) and 1 (5%), respectively, without reporting infections or requiring PP removal.Postoperatively, a satisfaction telephone survey was conducted in 19 (86%) patients: 16 (84%) considered the time of hospital stay as appropriate, 15 (79%) would have preferred to be operated again in an outpatient care setting and 15 (79%) would recommend it. The patients’ main concerns were related to being at home with no medical assistance at home and about coming back the next day for drainage removal. All patients reported well-controlled pain without requiring opioid intake in any case.ConclusionsIn our series, PP implantation in an ambulatory care setting is feasible and safe. Although there are some aspects that should be improved, the program showed acceptable satisfaction rates and an adequate postoperative pain control, neither raising the administration of opioids, nor increasing complications and re-admission rates.     

Open sutureless tension-free repair for primary inguinal hernia

Summary Since the first hernioplasty performed by Edoardo Bassini in 1884, all surgical reconstruction techniques have suffered from a common defect: tension on the suture line. This represents the main etiologic factor for recurrent hernia. With the introduction of modern prosthetic materials (meshes and plugs) it is possible to perform all hernia repairs without altering the normal anatomy, as well as avoiding undesired suture line tensions. Between January 1992 and December 1998 1405 open sutureless tension-free repairs were performed for primary inguinal hernia in 1317 patients. The number of patients treated with local anesthesia was 1235 (93.8%), with 63 (4.8%) treated under general anesthesia, and 19 (1.4%) with epidural anesthesia. In this series only 4 (0.3%) cases of intra-operative complication occurred (vagal crisis without consequences for the patients). Nine (0.6%) cases of early postoperative complications were noted, of which 8 involved vagal crisis and 1 hemorrhage. Forty six (3.4%) late postoperative complications occurred: 32 seromas accompanied by 3 massive inguino-scrotal edemas, 4 hematomas, and 10 wound infections without the necessity to remove the mesh in all cases. Six recurrences (0.4%) were noted after primary surgical repair. Mean follow-up time was 4 years (range 1–7 years). The proposed technique is simple, safe, and characterized by a rapid performing procedure giving an excellent outcome. The data presented confirms the experience of others reported in the world literature, with a low complication rate and lower cost for the community.     

Functional outcomes of primary and secondary repairs of vesicovaginal fistulae via vaginal cuff scar excision

Hospital and office charts of patients who underwent vaginal cuff scar excision for vesicovaginal fistula (VVF) repair from February 1998 to December 2002 at our institution were reviewed. Preoperative demographics and fistula characteristics were gathered. Intraoperative data included use of tissue flaps, blood loss, OR time and anesthetic type. Postoperative review included time to discharge, successful repair and postoperative urinary or sexual dysfunction. Forty fistula repairs were identified. Ninety-three percent occurred after a hysterectomy and no subjects had a history of radiation. Forty-two percent had failed at least one surgical repair of their fistula and 12% had failed two or more attempted repairs. Twenty percent of the fistulae measured 1 cm or more in diameter and the remaining 80% were 5 mm or less. Peritoneal flaps and martius flaps were performed in 32% and 5%, respectively. Postoperatively, 100% of subjects were evaluated at 3 weeks when the suprapubic catheter was removed and 93% were evaluated at 3 months or later. All subjects were cured of their fistulae at last contact. At 3 months postoperatively, 94% percent denied any urinary dysfunction and 85% had resumed sexual intercourse. Two sexually active subjects reported mild deep dyspareunia. Transvaginal cuff scar excision is an effective method for the primary and secondary repair of vesicovaginal fistulae and does not appear to cause postoperative irritative voiding symptoms or dyspareunia.Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of the United States Army, Department of Defense or the United States governmentThis article was presented at the 24th annual meeting of the American Urogynecologic Society, September 11–13, 2003. Hollywood, FL, USA Editorial Comment: Vesicovaginal fistula (VVF) is a most distressing problem for both the patient and surgeon alike. The most expeditious, safest, and least morbid repair with the greatest likelihood of success should be employed. These authors have previously described this approach for VVF repair and, now, in this article have published on functional outcomes. There is very little in the literature on long-term functional outcomes following VVF repair and therefore this represents an important contribution. Although the use of anonymous, complete validated questionnaires as an outcome measure would have been ideal, especially as regards urinary and sexual function, these authors report that functional outcomes following vaginal cuff excision repair of VVF are satisfactory. It is important to remember that the vast majority of patients presenting with VVF were healthy, presumably without significant urinary or sexual dysfunction, and underwent an elective surgery which created the problem. This paper suggests that these patients can be restored to a satisfactory level of urinary and sexual function following repair.     

Ambulatory anterior cervical discectomy and fusion is associated with a higher risk of revision surgery and perioperative complications: an analysis of a large nationwide database

Background Context

With the changing landscape of health care, outpatient spine surgery is being more commonly performed to reduce cost and to improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the most common spine surgeries performed and demand is expected to increase with an aging population.

Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: First 250 cases

BackgroundA growing body of evidence supports the laparoscopic sleeve gastrectomy (LSG) as a safe and effective procedure for sustained weight loss and amelioration of weight-related co-morbidities. Procedures performed in ambulatory surgery centers (ASC) can provide several advantages over hospital-based surgery. We present our results of 250 consecutive patients undergoing LSG in an ASC. The objective of this study was to assess the safety and efficacy of outpatient LSG in a freestanding ASC.MethodsData was collected prospectively from 250 consecutive patients who underwent LSG at a freestanding ASC. Patients were excluded from the ASC if they weighed>450 pounds, if anticipated operative time was>2 hours, if the patient had impaired mobility limiting early ambulation, or if there were medical problems requiring postoperative monitoring beyond 23 hours. Revisions were not included in this study.ResultsMean age was 47 years (range, 23–74 yr). Mean preoperative body mass index (BMI) was 43 kg/m² (29–71 kg/m²). Mean operative time was 60 minutes (31–161 min). Mean recovery room time was 131 minutes (30–385 min). Mean percent excess weight loss (%EWL) was 60% at 1 year and 63% at 2 years. Nine patients (3.6%) were readmitted within 30 days. Two patients (.8%) were transferred from the ASC to a hospital. There was 1 staple line leak (.4%). There were no open conversions and no deaths.ConclusionsLSG can be performed safely in a freestanding ASC in select patients with outcomes comparable to the inpatient standard. Additional studies are needed to formulate selection criteria and guidelines to maximize patient safety and outcomes.     

Predicting failure of outpatient laparoscopic cholecystectomy

BACKGROUND: Outpatient laparoscopic cholecystectomy (LC) is safe and feasible, but factors related to the failure of outpatient surgery are poorly defined. We hypothesized that patients in whom same day discharge (SDD) is unlikely may be identified preoperatively. METHODS: Three hundred eighty-seven consecutive patients scheduled for elective LC were prospectively enrolled in an outpatient clinical pathway. RESULTS: In all, 269 (70%) patients successfully underwent outpatient LC. Factors related to failure of SDD were age, American Society of Anesthesiology (ASA) class, surgery start time, and duration of surgery. Body mass index, liver function tests, and ultrasound findings did not predict failure of SDD. Three factors were able to predict more than 50% failure of SDD: age more than 50 years, ASA class 3 or more, and surgery start time later than 1:00 PM. CONCLUSIONS: Outpatient LC is feasible in a large county hospital. These data may be used in scheduling cases and counseling patients.     

Using the parents' video camera for the follow-up of children who have undergone hypospadias surgery decreases hospital anxiety of children

Purpose

We investigated the benefits of using the parents' video camera records for the follow-up of children who had undergone hypospadias surgery in terms of reducing fear and hospital anxiety of the children and the time spent in the waiting room.

Methods

This prospective study was performed on children with proximal hypospadias. The patients were called for the follow-up appointment on the 7th postoperative day and were divided into 3 groups. The first group was the control group where parents were not given any follow-up visit direction. The parents of the second group were told to have their child drink enough fluids and come with a full bladder, while the third group of parents recorded their child's micturition using a video camera. The fear and anxiety of children at the postoperative visit were evaluated and recorded using a scoring system between 0 and 4 using the Children's Fear Scale (CFS) brochure. The time elapsed from the arrival of the parents in the outpatient clinic to their departure was also recorded for comparison of the total time spent during the follow-up visit among the groups.

Results

Thirty boys who underwent hypospadias repair were enrolled in this study. The median CFS scores at the postoperative follow-up visit were 2.99 ± 0.99 (range: 1–4) in the first group, 2.90 ± 0.87 (range: 1–4) in the second group, and 0.00 (range 0–0) in the third group. The median total time spent during the follow-up visit in the 3 groups was 61.50 ± 17.08 (range 35–88), 18.1 ± 13.01 (range 4–45), and 4.0 ± 0.81 (3–5) minutes, respectively. Both CFS and total time spent were significantly lower in the third group (p < 0.01).

Conclusion

Imaging of micturition at home by using a video camera for outpatient visits following hypospadias surgery will decrease the fear and anxiety of children and the time that the family spends at the hospital.