Audit of day case maxillofacial surgery: a pilot assessment

The aim of this study was to design and evaluate an audit structure for day case maxillofacial surgery, which may be applied to other surgical specialities. Retrospective and prospective data collection over a 3-month period revealed that the clinical standards set in advance of the audit procedure were achieved in five of the 11 criteria. In only two instances were the standards not met, only 46% of patients were seen within 3 months of the referral, against the 95% desired standard, and only 50% had surgery within 3 months of being seen, against the 95% standard. Future audit should be prospective but action should be taken as necessary to address the significant failure in achieving the set standards, thus completing the audit cycle.     

日间手术麻醉离院标准

背景 日间手术已经成为麻醉医生工作的一个主要部分.一例成功的日间手术麻醉很大程度上取决于使患者尽早而安全地离院,因此迫切需要我们制订出公认的合理的安全性高的离院标准.目的 分析总结国内外学者制订的各种离院标准的文献资料.内容 分析Aldrete评分、麻醉后离院评分系统(postanesthetic discharge ...     

机器人辅助神经鞘瘤切除日间手术一例报道

神经鞘瘤是一种常见的后纵隔占位性病变,通常发生于脊神经根,具有一定的恶变可能性。临床上对于后纵隔占位性病变,若无禁忌证,均应考虑外科治疗。手术方式根据肿瘤的大小和位置分为开胸手术以及胸腔镜手术。尽管后纵隔肿瘤切除术通常被认为是一种安全的、低风险的手术,但患者术后仍需要住院观察。随着手术机器人技术的开发,机器人辅助手术可以保护周围组织减少术后出血的可能性,以达到日间手术的标准。本文介绍了一例接受机器人辅助后纵隔肿瘤切除日间手术的患者,手术效果满意,患者在24h内顺利出院。     

腹腔镜腹股沟疝修补术日间手术模式的临床效益评价

目的比较日间手术模式和住院手术模式在腹腔镜腹股沟疝修补术的临床效益。方法选取2017年1~12月昆明医科大学第二附属医院就诊的120例单侧腹股沟疝患者作为研究对象。将所有患者按照随机数字表法随机分成日间手术模式组和住院手术模式组,各60例。观察2组患者的手术时间、术中出血量、术后下床活动时间、尿潴留发生率、阴囊积液发生率、异物感发生率、总并发症发生率、医疗费用及满意度。结果所有患者均顺利完成手术,半年随访期内无复发。日间手术模式组与住院手术模式组患者的手术时间、术中出血量、术后下床活动时间、尿潴留发生率、阴囊积液发生率、异物感发生率、总并发症发生率比较,差异均无统计学意义(P>0.05)。日间手术组患者住院时间要明显比住院手术组患者短,日间手术组患者总住院费比住院手术组患者低,日间手术组患者对治疗过程满意程度明显高于对照组患者,差异均有统计学意义(P<0.05)。结论日间手术模式下行腹腔镜腹股沟疝修补术安全有效,且可降低总费用,加快周转率,提高了医疗资源的利用率,提高了患者的满意度。     

Pain relief following oral day case surgery: a pilot study

One hundred consecutive, adult patients attending for bilateral mandibular third molar removal utilising standardised surgical and day case general anaesthetic protocols were recruited into a pilot study to investigate the effectiveness of different peri-operative analgesic regimes. Patients were randomised into five study groups using various pre- or post-operative combinations of non-steroidal anti-inflammatory drugs (NSAID) and/or LA block. Pain scores were recorded pre-operatively and at 30 min intervals for 2 h after surgery, as were details of the first dose of ‘escape analgesia’ (codeine/paracetamol compound preparation). There was no statistically significant difference in overall pain experience between the groups, although the results suggested better pain relief was achieved in those patients who received both post-op NSAID and post-op LA. Further research is required to improve post-operative pain relief for patients undergoing third molar surgery.     

Mivacurium chloride for anesthesia in day surgery

Anesthetic techniques for day surgery must foresee a prompt recovery of alertness, ambulation and alimentation. The aim of our study is to evaluate mivacurium chloride in outpatient general anesthesia. Twenty patients, aged 18–55 years, American Society of Anesthesiologists (ASA) class I–II, undergoing surgical procedures were studied. Mivacurium (0.2 mg/kg) was administered to provide neuromuscular relaxation and endotracheal intubation was performed. Additional doses of 0.1 mg/kg mivacurium were given to maintain neuromuscular block, monitored by Relaxograph (Datex). In all patients, mivacurium provided satisfactory conditions for tracheal intubation after a mean time of 120 ± 15 s. Spontaneous recovery after the last dose of mivacurium was obtained in a mean time of 15 min. No side-effects or significant hemodynamic changes were recorded. The incidence of histamine-related side-effects was low. Mivacurium produces spontaneous recovery of neuromuscular block in a short time and shows some ideal properties for anesthesia in day surgery.     

Economic impact of cancellous bone grafting in trauma surgery

Introduction Cancellous bone grafting is currently the most frequent method for replacement of bone material. In recent years, several alternative methods came into practice. However, up to now it remains unclear whether cancellous bone grafting is cheaper as compared to these new methods. Therefore, the aim of this study was to calculate the direct costs of cancellous bone grafting. Materials and methods For calculation of the direct costs operation time needed in addition to the main surgical intervention was measured and the material used recorded in a consecutive series of 50 interventions including bone grafting at the Department of Trauma Surgery at the University Hospital of Bonn Medical School. Surgical staff costs were calculated on the basis of a standard team consisting of one surgical attendant, surgical resident, surgical nurse, and nurse’s service. Cost of anaesthesia was calculated on a per minute base. Results Mean additional operation time was 26.3 min (range 17–35 min). Surgical staff costs per operation minute were 2.70 Euro, costs for anaesthesiological service were 4.18 Euro/min. Material additional used consisted of sutures and sterilization costs. Material costs summed up to 32.01 Euro. The total direct costs of bone grafting were 212.95 Euro. Conclusion The direct costs of harvesting cancellous bone graft and the use of bone replacement material are comparable. Due to the high complication rate at the donor site the total-cost-of-illness might be higher when using autologous bone graft.     

机器人辅助肺癌根治日间手术的要点探析

快速康复理念正逐渐被外科医生所接受,而日间手术是快速康复理念的集中体现。机器人手术操作灵活、精确、平稳,其微创能力较传统胸腔镜手术更加明显,因此更加适合应用于日间手术。目前,机器人肺外科日间手术在国内尚未大量开展,其术中、术后管理经验仍较为缺乏。笔者所在医院在大规模开展机器人手术的基础上,进行了少量机器人肺外科日间手术的尝试。本文主要针机器人肺外科日间手术的患者选择、手术体位、手术方式、术中特殊情况处理等进行经验总结,为未来机器人肺外科手术围手术期的规范化提供思路。     

机器人辅助日间肺癌手术的麻醉

随着低剂量CT筛查的推广,早期肺癌手术的需求量明显增加。经过严格筛查,部分患者可以进行日间肺癌手术。与电视胸腔镜手术和开放手术相比,机器人辅助胸科手术的创伤更小,可能更有利于患者的快速康复。同时,机器人辅助日间肺癌手术也对麻醉全流程提出了更高的要求。本综述以加速康复外科的原则和方法为基础,根据日间手术和机器人辅助肺癌手术的特点,从术前麻醉评估、术中麻醉管理、术后随访及出院标准等方面对机器人辅助日间肺癌手术的麻醉要点进行探讨。     

The South Tyneside FASTRAK service: evaluation of a new model for day surgery

Objective: To evaluate a service (FASTRAK) offering general practitioners direct access to day surgery operative waiting lists, based on explicit guidelines regarding patient suitability for surgery and anaesthesia. Design: Notes abstraction for a cohort of patients referred via FASTRAK and a cohort referred via conventional day surgery routes; postal questionnaire survey of patient satisfaction amongst FASTRAK patients and matched controls referred via conventional routes; postal survey of professional satisfaction. Setting: One district general hospital in the north east of England, and all general practices in that district. Subjects: 1278 patients (1100 conventional day case patients; 178 FASTRAK patients) for notes abstraction; 70 patients for patient satisfaction survey 83 general practitioners for professional satisfaction survey. Main outcome measures: interval from referral to operation, and appropriateness of referral; patient experience and satisfaction with hospital and post-discharge care, especially with respect to information provision, for patient survey; overall rating of service, perceived benefits and disadvantages and future intentions for professional satisfaction survey. Results: The interval from referral to operation was significantly shorter for FASTRAK patients by a median of 91 days. Out of a total of 178 FASTRAK referrals, only seven (4%) were inappropriate whilst diagnosis was wrong in three (2%) cases. Patients referred via FASTRAK were much more likely to have received written information prior to admission (83 vs. 37%: χ²=12.25. P=0.0019). General practitioners (GPs) had positive views of the service; 94% rated it as ‘fair' to ‘very good'. GPs, 90%, perceived the main benefit to patients to be a shorter waiting time for operation; 40% felt that the availability of clear information for patients benefited doctors. Increased general practitioner workload was recognised as a disadvantage (61%) and the main barrier to use of the service was lack of eligible patients under the current guidelines (69%). Conclusions: When diagnosis, indication for surgery and fitness for anaesthesia are not in doubt, general practitioners, given appropriate guidance, are able to provide all the necessary pre-operative services that are usually provided in the general surgical outpatient clinic, without prejudicing the quality of care or decreasing patient satisfaction.     

新型护理流程在腹股沟疝日间手术患者中的应用

目的探讨新型护理流程在腹股沟疝日间手术患者中的应用。 方法选取2018年6月至2019年6月,首都医科大学附属北京朝阳医院疝和腹壁外科日间腹股沟疝手术患者224例,采用随机数字表法将患者分为试验组和对照组,每组112例。2组患者均行腹股沟疝修补术,对照组患者采用普通病房日常管理模式,给予常规护理;试验组患者应用新型护理流程。2组术后均随访2～6个月,比较2组患者对护理的满意度、患者对腹股沟疝疾病知识知晓率及护士错误率、工作时间。 结果试验组总满意度高于对照组,差异有统计学意义（P<0.05）。试验组患者对疾病知晓率高于对照组,试验组护士错误率低于对照组,试验组护士工作时间明显少于对照组,差异均有统计学意义（P<0.05）。 结论对日间腹股沟疝手术患者运用新型护理流程进行病房管理,优化了医护人员工作流程,提高护理工作质量,提高了患者对疾病知晓程度,增加了参与感,整体就医感受满意度明显提高。同时护理资源得到有效利用,具有推广的价值。     

Compliance with postoperative instructions: a telephone survey of 750 day surgery patients

Patients undergoing day surgical procedures are given postoperative instructions not to drink alcohol, drive vehicles or make important decisions for 24 h. They are also advised to have a responsible adult stay with them at home overnight. Seven hundred and fifty patients were telephoned at 24 h postoperatively to determine their compliance with these instructions. Four per cent of patients drove vehicles, 1.8% consumed alcohol, while one patient made an important decision. A higher proportion of patients (5%) drove after general anaesthesia than regional anaesthesia or intravenous sedation (2.4%). The percentage of patients consuming alcohol was similar in both groups (1.8% vs. 1.9%). Four per cent of patients had no one staying with them overnight despite being accompanied out of the hospital. Patient compliance with instructions to not drink alcohol, drive or make important decisions may be improved by physician reinforcement of instructions and patient education.     

Cost considerations in trauma and emergency laparoscopy

Summary BACKGROUND: There are a number of laparoscopic procedures in trauma and emergency surgery that to some extent at least have passed the test of being safe and feasible with short-term results equaling those of the open procedure. The only justification for an increase in total costs, however, is improved outcome. If the actual procedure inside the body is identical whether performed laparoscopically or openly, and both methods yield comparable short-term outcomes, the differences in the morbidity and costs are attributable to the size of the access wound (affecting the hospital and recovery times), the length of the operation, and the equipment needed. METHODS: Cost analyses in trauma and emergency laparoscopy, limited to those laparoscopic procedures in trauma and emergency surgery which to some extent have passed the test of feasibility and efficacy are reviewed. RESULTS: Currently available evidence on the use of laparoscopy in most trauma and emergency procedures or management strategies offers little support from the cost efficacy point of view to favor the minimally invasive alternative. There are some procedures, however, such as laparoscopic resection of uncomplicated sigmoid diverticulitis, laparoscopic cholecystectomy for acute cholecystitis, or the management of ectopic pregnancy, for which the lower community cost might justify the somewhat higher hospital costs associated with the laparoscopic approach. CONCLUSIONS: Until properly designed, controlled studies show true improvement in cost efficacy of the minimally invasive alternative in individual surgical procedures or management strategies, a critical view in applying laparoscopy in trauma and emergency surgery must be maintained.     

机器人胸外科日间手术体系构建

日间手术在胸外科领域的应用目前仍处于起步阶段,而近年来机器人辅助胸腔镜手术在胸外科的应用为胸外科日间手术的推广普及带来了新的契机。为了总结近年来机器人胸外科日间手术诊疗过程的相关经验,规范机器人胸外科日间手术实施的相关流程,中南大学湘雅医院胸外科联合中国医师协会医学机器人分会的相关专家,借鉴国内外已有的机器人胸外科日间手术经验构建了机器人胸外科日间手术体系,旨在为国内机器人胸外科日间手术的开展提供参考指导。     

腹股沟疝日间手术患者护理模式的探讨与分析

目的探讨与分析日间手术治疗腹股沟疝患者的护理模式。 方法回顾性分析2017年1月至2019年1月,首都医科大学附属北京朝阳医院疝和腹壁外科就诊的3266例腹股沟疝日间手术患者。其中,儿童疝患者1111例（34.0%）,成人疝患者根据手术方式不同分为开放组和腹腔镜组。开放组患者1256例（38.46%）,腹腔镜组患者例899（27.54%）,记录全部患者围手术期护理的并发症与相应的处理对策。 结果所有患者手术过程顺利,儿童疝组围手术期出现尿浸湿伤口敷料24例（2.2%）,活动后出现伤口敷料脱落13例（1.2%）,急性疼痛21例（1.9%）;成人疝组围手术期出现排尿困难48例（2.2%）,急性疼痛69例（3.2%）,发热33例（1.5%）,体位性低血压12例（0.6%）,恶心呕吐20例（0.9%）;所有成人组患者围手术期出现特殊事件5例（0.2%）,术后转普通病房7例（0.3%）,夜间再次急诊就诊11例（0.5%）。所有患者随访期间均未出现伤口感染、液化等并发症。 结论在日间手术治疗腹股沟疝患者的围手术期中,良好的腹股沟疝日间手术护理模式,以及定期密切的随访,能显著提升临床治疗效率,有助于减少患者围手术期并发症的发生及早日康复。     

Development and efficiency of an acute knee trauma list

Following acute knee trauma some patients will require urgent arthroscopy. Traditionally surgery is undertaken as in-patient on the general trauma list. This system leads to blockage of beds, repeated starving of the patient and out-of-hour's surgery in many cases. We introduced a dedicated Day Surgery knee trauma list (KTL) to reduce in-patient admissions, waiting time and cost. The typical indications for urgent knee arthroscopy are locked knees secondary to meniscal tears, loose bodies or cruciate ligament ruptures; acute osteochondral fractures; and children with acute meniscal tears. This retrospective review compares the study group: patients on the knee trauma list during the first 8 months following introduction, and the control group: patients on the general in-patient trauma list over a similar period immediately prior to implementation of the new list. There were 49 patients in the control group with an average stay in hospital of 2.5 days. Out-of-hour's operations were performed in 13 patients and 3 patients required a repeat arthroscopy. Fifty-three patients were treated in the knee study group. The significant operations were meniscal repair in 7, fixation of osteochondral fragments in 3. None of the patients required overnight stay. Control group patients were more likely to have surgery performed by inexperienced non-specialist knee surgeons, whereas specialist knee surgeons staffed the knee trauma list. Specialist surgeons were available to staff the knee trauma list. As the majority of the control group had spent an average of 2.2 nights in hospital, there has been considerable savings to the hospital. Introduction of the Day Surgical Knee trauma list has reduced unnecessary admissions per week; episodes of prolonged starving, cost and have improved patient satisfaction and management.     

Introduction of a hand trauma day surgery operating list

Due to a huge increase in hand trauma referrals to our busy plastic surgical unit, we introduced a dedicated half-day hand trauma day surgery (HTDS) list to try and reduce the pressure on inpatient beds and length of wait for surgery. We reviewed the first 101 cases treated on the HTDS list to determine whether this allowed adequate specialist treatment of these injuries and to assess outcome and complications rates. Only one patient needed admission following surgery and our complication rate compared favourably with that of patients admitted and treated in the standard manner. We conclude that a HTDS list is both an effective and efficient method of treating a wide range of hand injuries.     

Minor operations performed under local anaesthetic in a day surgery unit

Minor ‘lumps and bumps' requiring operation under local anaesthetic constitute a significant number of referrals each month to general surgical clinics. These patients have often remained on hospital waiting lists for more than 1 year. A new system for managing these cases is presented whereby: (i) a large throughput of ‘clinical material' is available for supervised teaching of both medical students and junior trainees; (ii) patients are operated upon safely and efficiently; (iii) the waiting list time can be significantly reduced; and (iv) the patient has an overall satisfactory hospital ‘experience'.     

Laparoscopic day surgery: the process of recovery for women

Day surgery procedures are rapidly increasing in number and complexity and will continue to do so in line with government policy. These changes warrant an assessment of the effect of decreased contact with medical and nursing professionals, particularly in the postoperative recovery phase. Semi-structured interviews used to investigate women's experiences of laparoscopic day surgery and their perceived recovery revealed that women in the study were not optimally prepared for the experience. In particular, they were surprised about the severity and duration of pain, extent of the disability, the level of disruption to their work and home lives and the need for physical and emotional support following the procedure. These findings have implications for pre- and postoperative education, community support services and aftercare.     

机器人胸外科日间手术的现状与展望

术后加速康复理念的推广与普及令日间手术的实践成为目前外科诊疗模式发展的重要议题,而胸外科手术的诸多特点使胸外科日间手术的推广面临诸多障碍。外科诊疗技术在近二十年的发展突飞猛进,其中机器人辅助手术的技术突破使诸多复杂外科手术的开展效率得到了飞跃性提升。因此,这一技术在胸外科日间手术的应用或将成为胸外科日间手术发展的新里程碑。本文结合已有研究成果,梳理总结了胸外科日间手术与机器人辅助手术的发展历程,并对两者未来的结合运用前景进行了展望。