Ambulatory Surgical Unit Research Articles

Modified open laparoscopy through placement of an optical surgical obturator

Objective: To describe a new technique for open laparoscopy. Design: Prospective case series. Setting: Ambulatory surgical unit. Patient(s): Fifty-six women undergoing laparoscopic sterilization. Intervention(s): Intra-abdominal placement of an optical surgical obturator. Main Outcome Measure(s): Evaluation of surgical technique. Result(s): The technique was completed successfully in all cases. Conclusion(s): This new surgical approach may assist surgeons in avoiding inadvertent injuries.

Practical points in theevaluation of postoperative fever

The finding of an elevated temperature in the PACU or ambulatory surgical unit in and of itself is not the challenge facing either the patient or the nurse. The challenge is in the interpretation of the finding, the outcomes of the alterations in temperature, and the physiologic sequellae that accompany the elevation.

Total intravenous anesthesia and high-frequency jet ventilation during transthoracic endoscopic sympathectomy for treatment of essential hyperhidrosis palmaris: A new approach

To evaluate the effects of high-frequency jet ventilation (HFJV) applied to both lungs on hemodynamic parameters, oxygenation, and operating conditions during bilateral videothoracoscopic sympathectomy. A prospective, unblinded study. An ambulatory surgical unit at a university medical center. 30 patients (11 men, 19 women), ASA status 1. Bilateral videothoracoscopic sympathectomies were performed using total intravenous anesthesia with propofol, alfentanil, and atracurium, and the patients were ventilated with an oxygen-air mixture using HFJV delivered to both lungs with a Hi-Lo Jet tracheal tube (Mallinckrodt). Mean total anesthesia time was 55 +/- 13 minutes. Hemodynamic parameters remained stable during surgery, although ablation of the sympathetic ganglia induced three incidences of bradycardia (10% of the patients), which were responsive to atropine. Four patients developed oxygen desaturation (Sa O2 < 90%) after the creation of the pneumothorax. Surgical conditions were considered excellent by the surgeons. Concerning postoperative complications, a temporary Horner's syndrome was observed in one patient. Another patient had a mild residual pneumothorax on the first postoperative day that resolved without insertion of a chest tube. It was concluded that HFJV applied to both lungs is an easy and safe anesthetic technique that provides excellent surgical conditions and causes a minor incidence of morbidity.

Comparison of the abdominal wall stability of Endopath Optiview with the standard laparoscopic cannula

We conducted a prospective trial to compare the intraabdominal wall stability of the sheath of the Endopath Optiview with that of a conventional reusable cannula. In 100 consecutive women undergoing elective laparoscopic sterilization in an ambulatory surgical unit, we alternately used a standard reusable 10-mm cannula (group A) or the Optiview 10- to 12-mm cannula (group B) to establish the intraabdominal surgical port. Single-incision bipolar laparoscopic tubal occlusion was performed, and the force required to remove the cannula sheath from the abdominal cavity was determined by spring-loaded force gauge. The mean (&plusmn; SEM) peak force required to remove the cannula sheath in group A was 2.25 &plusmn; 0.19 lbs. The comparative value for group B was 5.32 &plusmn; 0.28 lbs. (p <0.005). The in situ operative sheath of the Endopath Optiview has greater intraabdominal wall stability than a standard reusable cannula.

Low-dose propofol for the treatment of postoperative emesis in children

The objective of this study was to determine the efficacy of intravenous (iv), low-dose propofol for the treatment of postoperative emesis in children. We performed a randomized, prospective, double-blind, placebo-controlled investigation in the ambulatory surgical unit on 90 healthy children, aged 1–16 yr following elective, outpatient surgery. After an episode of postoperative vomiting, patients were randomized to receive iv propofol, 0.25 mg kg −1, or an equivalent volume of 10% lipid emulsion (Intralipid ®). A second dose of study drug was administered if emesis recurred. All episodes of emesis and postinjection sedation scores following study drug administration were recorded. The study was terminated after analysing the results of 45 children in each group. There were no complications in either study group. We concluded that propofol 0.25 mg kg −1 was not an effective treatment for postoperative emesis in healthy children undergoing elective outpatient surgery. It is possible that increasing the dose and/or the duration of administration may improve propofol's ability to treat postoperative emesis in children.

Outpatient Nephrectomy for Nonfunctioning Kidneys

We describe a surgical approach that allows multicystic dysplastic and nonfunctioning hydronephrotic kidneys to be removed on an outpatient basis through a 2.5 to 3 cm. subcostal incision. In the last 5 years 40 children (age 4 months to 5 years, mean 8.2 months) were scheduled for outpatient nephrectomy in an ambulatory surgical unit in a hospital setting. Of the 40 patients 30 had a multicystic kidney. Renal size ranged from 3 X 2 to 9.5 X 7.2 cm. Operative time ranged from 20 to 70 minutes (mean 45.4). In 34 cases (85 percent) an intercostal block was also performed to provide analgesia for 18 to 24 hours. Nephrectomy was done on an outpatient basis in 39 of the 40 children (98 percent). Mean pain score (range 0 to 5) in the last 19 patients who underwent an intercostal block was 0.68 at discharge from the hospital, 0.85 at bedtime and 0.95, 24 hours later. We conclude that nephrectomy may be performed through a small incision on an outpatient basis with minimal morbidity, and that this approach offers an alternative to laparoscopic nephrectomy and nonsurgical management of these kidneys.

Outpatient Nephrectomy for Nonfunctioning Kidneys

We describe a surgical approach that allows multicystic dysplastic and nonfunctioning hydronephrotic kidneys to be removed on an outpatient basis through a 2.5 to 3 cm. subcostal incision. In the last 5 years 40 children (age 4 months to 5 years, mean 8.2 months) were scheduled for outpatient nephrectomy in an ambulatory surgical unit in a hospital setting. Of the 40 patients 30 had a multicystic kidney. Renal size ranged from 3 x 2 to 9.5 x 7.2 cm. Operative time ranged from 20 to 70 minutes (mean 45.4). In 34 cases (85%) an intercostal block was also performed to provide analgesia for 18 to 24 hours. Nephrectomy was done on an outpatient basis in 39 of the 40 children (98%). Mean pain score (range 0 to 5) in the last 19 patients who underwent an intercostal block was 0.68 at discharge from the hospital, 0.85 at bedtime and 0.95, 24 hours later. We conclude that nephrectomy may be performed through a small incision on an outpatient basis with minimal morbidity, and that this approach offers an alternative to laparoscopic nephrectomy and nonsurgical management of these kidneys.

Anesthesiology

Health care system reform calls for providing patients with cost-effective care in settings as diverse as the ambulatory surgical unit or the intensive care unit. Senator John D. Rockefeller IV¹applauds the efforts of Johnstone and Martinec²as groundbreaking work that allows us to understand the true costs of anesthesia services. By organizing and defining the components and determinants of anesthesia costs, these investigators from West Virginia University, Morgantown, draw attention to the fact that anesthesia providers control at least 3% to 5% of total annual health care costs in the United States—$9 billion for provider services and $11.7 billion for preoperative testing. The Committee on Professional Liability of the American Society of Anesthesiologists has undertaken an initiative to reduce health care costs related to professional liability.³Their comparison of pediatric and adult anesthesia closed malpractice cases shows substantial differences. Mishaps with inadequate ventilation occurred more frequently

Outpatient mediastinoscopy

The reported experience with outpatient mediastinoscopy is limited. We have performed 65 mediastinoscopies in a hospital-based ambulatory surgical unit during the past 2 1/2 years. This represents 54% of our total mediastinoscopies during the period and 85% of the total for the past year. One patient was admitted overnight because of hypoxemia that was relieved by thoracentesis. All other patients were discharged from the outpatient recovery room without problems. No other early and no late complications occurred. The cost savings were substantial, and patient satisfaction was high. We conclude that mediastinoscopy can be performed safely in the outpatient setting in many patients.

Use of CO2 laser in treatment of molluscum contagiosum: Reports of four cases

Study Objective: To assess the use of the CO2 laser in the management of ano-genital molluscum contagiosum.Design: Case series.Setting: Ambulatory surgical unit in a large pediatric hospital.Participants: Three girls and one boy who were seen for management of extensive ano-genital molluscum contagiosum between 1988 and 1992 were included in this study.Interventions: The CO2 laser was used to ablate all lesions in each patient.Main Outcome Measures: Resolution, persistence, recurrence of lesions, and scarring of the surgical sites.Results: All patients were noted to have good healing of the surgical sites without scarring or deformities. No recurrences were noted.Conclusion: The CO2 laser is yet another instrument at the disposal of the gynecologist for the treatment of extensive ano-genital molluscum contagiosum in the pediatric age group.

Early anesthesia evaluation of the ambulatory surgical patient: Does it really help?

Study Objective: To evaluate whether early, evaluation by the anesthesiologist is more beneficial for the ambulatory surgical patient than a day-of-surgery visit. Design: A randomized study evaluating patients with different surgical procedures. Setting: Ambulatory surgical outpatients at a university-affiliated integrated ambulatory surgical unit. Patients: Sixty-three ASA physical states I and II women scheduled to undergo elective dilatation and curettage or gynecologic laser surgery. Interventions: Approximately half of the patients received an early (1 to 7 days preoperative anesthesia evaluation, and half received a day-of-surgery evaluation. All patients underwent the surgical procedures with a standardized general anesthetic. Measurements and Main Results: The effect of an early versus a day-of-surgery anesthesia visit was evaluated with regard to patient anxiety levels; patient satisfaction with the surgical and anesthetic experience; operating room, recovery room, and ambulatory surgery unit time; anesthetic and analgesic requirements; and frequency of postoperative problems within 72 hours at home. There were no differences between the groups in demographic characteristics, anesthesia or analgesic requirements, degree of satisfaction with the ambulatory surgical experience, time spent in recovery room, or frequency of problems on postoperative follow-up. We were unable to demonstrate any differences between those patients seen early versus those seen on the day of surgery in anxiety levels preoperatively and postoperatively. Conclusions: Healthy ASA physical status I and II ambulatory surgical patients do not benefit from reducing preoperative anxiety by visiting the anesthesiologist prior to the day of surgery.

The Impact of an Ambulatory Surgical Service in a Community Hospital

The purpose of this study was to quantify the savings accrued from shifting surgical cases from an inpatient to an outpatient setting. There was no increase in the total number of operations from 7952 in 1973 to 10,250 in 1987. The percentage of ambulatory procedures showed a continuous increase from 17.9% to 56.3%. The 15-year experience accumulated at this institution now exceeds 43,000 cases, with no mortality. The study closely examined hospital charges, not costs, for 2 months, which were then annualized. The calculated average savings per case was $2000 and 3.07 hospital days. The estimated savings for fiscal 1987 were $11.5 million and 17,726 hospital days. Based on this experience, the operation of an in-hospital ambulatory surgical unit is recommended as a cost-saving, safe, and efficient method of performing many surgical procedures.

Major Ambulatory Surgery of the General Surgical Patient: Management of Breast Disease and Hernias of the Abdominal Wall

Procedures for management of breast disease and abdominal wall hernias are those that are done most commonly by the general surgeon and for which the ambulatory surgical unit is apt to be the preferred site. Surgical technique for the management of the various forms of breast disease is reviewed. Most hernias of the abdominal wall can be repaired safely, conveniently, and comfortably in the ambulatory surgical unit. Except for large hernias, no type of hernia should be categorically denied consideration for ambulatory care.

The Major Ambulatory Surgical Center and How It Is Developed

Of the more than 20 million surgical operations performed each year in this country, 40 to 50 per cent can be done without hospitalizing the patient, and more and more of these out-of-hospital operations are being done on patients requiring general anesthesia or a period of postoperative observation. This article reviews the advantages and disadvantages of major ambulatory surgery in general, as well as those of the different types of ambulatory surgical units. The steps in the development of a unit, including the various committees involved in its development and operation, are outlined.

Major Ambulatory Surgery of the General Surgical Patient: Management of Anorectal Conditions, Peripheral Vascular Problems, and Gastrointestinal Endoscopy

The growing experience with controlling postoperative pain and with using Foley catheters postoperatively has made surgeons less hesitant to perform some anorectal procedures in an ambulatory setting. Procedures for the treatment of varicose veins of lesser severity can often be done in an ambulatory surgical center. Because of the risk for respiratory complications and perforations, some endoscopic procedures are appropriate for the major ambulatory surgical unit.

A freestanding ambulatory surgical unit: A success or failure?

The concept of a freestanding ambulatory surgical center was to provide the patient with a more cost-effective, safe, and convenient service. A study of 5,369 surgical patients treated at the Northeast Louisiana Surgical Center, Inc., in Monroe, Louisiana, was carried out to determine whether these objectives had been met. The finding was that a freestanding ambulatory surgical center was more cost effective than either a hospital ambulatory unit or an in-hospital service. The infection rate was 0.06%, and the hospital transfer rate was 0.04%. The concept of a freestanding ambulatory surgical center has fulfilled the expectations of safety, convenience, and cost effectiveness for the patients.

Hospital Ambulatory Surgical Units

Hospital Ambulatory Surgical Units

Developing the ambulatory surgical unit: the physician's responsibility.

Developing the ambulatory surgical unit: the physician's responsibility.

A blueprint for day surgery

A blueprint for day surgery

Ferguson's Surgery of the Ambulatory Patient

This new and extensively revised edition of the classic textbook of ambulatory surgery has been thoughtfully prepared to meet the challenges presented by the current crisis in delivery of health care, + particularly the rapidly rising costs of inpatient surgical care. The editor has succinctly described the indications and principles that govern the selection of patients for ambulatory surgery, and the book is introduced with an excellent chapter on the planning of an ambulatory surgical unit. The traditional regional anatomical approach is effectively utilized throughout the book, with particularly strong sections on the scalp, face, salivary glands, breast, perianal region, back, genitourinary system, and extremities. Surgical patients usually are admitted with a reasonably well-localized complaint, so the value of the regional approach to diagnosis and treatment is clearly apparent. The chapters on anesthesia, dressings and bandages, wounds, infections, bites, burns, frostbite, and foreign bodies are all excellent, with an appropriate balance