Download - Ambulatory Laparoscopic Surgery
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Dr M G Bhat30/03/2014, Gokak
Consultant SurgeonMinimal Access and Bariatric SurgeryNova Specialty Hospital, Koramangala Bangalore
Medical DirectorNova Medical Centers Pvt Ltd, India
Greetings From….
Dr. M G BhatMS, FRCS(England), FRCS ( Edinburgh), FICSDMLE (Law), DMIRCSEd (Informatics)
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Dr M G Bhat
Ambulatory Laparoscopi
c Surgery
30/03/2014, Gokak
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Dr M G Bhat30/03/2014, Gokak
1. Of, relating to, or adapted for walking.
2.a. Capable of walking; not bedridden an ambulatory patient.b. Designed for or available to
patients who are not bedridden: ambulatory care; ambulatory pediatrics..
am·bu·la·to·ry
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Dr M G Bhat30/03/2014, Gokak
Ambulatory Surgery
Office Surgery Patient Recovers from Surgery and fit to return home within few hrsAmbulatory Surgery
Patient recovers from Surgery and fit to return home the same evening without overnight stay
The Day Care Surgery Patient Recovers from Surgery and fit to return home within a day or 24 hrs
Short Stay Surgery Upto 72hrs
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Dr M G Bhat30/03/2014, Gokak
Changes Brought in by Minimal Access Surgery
• Change in the Entire Concept of Recovery• Fast Tracking of Surgery• Early Recovery and Discharge
• No NG Tubes• No Drains• Early Feeding• Early Mobilization
19731976
1991
2000
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Dr M G Bhat30/03/2014, Gokak
Short Stay Surgery72hrs Stay
•Comfort Level & Flexibility•Bariatric Surgery•Spine Surgery•Knee Replacements•Bigger Surgeries in Fit Patients•70% of all Surgeries
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Dr M G Bhat30/03/2014, Gokak
Concept :… Early Discharge
• Mobilse Early• Feed Early• Control Pain• Safety &
Quality
In 2008: 20% of the surgeries were day care in India.In J Med Sci. 2008;3(3):101-116.
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Dr M G Bhat
How to Discharge Early?
30/03/2014, Gokak
• Select a Good Patient• Select a Good Case• Select Good Infrastructure Hospital
Good Risk Patient
Avoid Complex Case
Hospital with Good Support
Elective Cases
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Dr M G Bhat
Pre Operative
30/03/2014, Gokak
• Clinical Evaluation• Investigations• Assessment• Planning• Suitability• Motivating• Financials • Fix Date of Surgery
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Dr M G Bhat
Operation – Surgery Day
30/03/2014, Gokak
• Admission in the morning (patient comes prepared)
• Early Surgery ( No Waiting)
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Dr M G Bhat30/03/2014, Gokak
GI:• Cholecystectomy
• Appendicectomy
• Hernia• Diagnostic• Gynecology• Bariatric• Colo Rectal• Others
Others• General • Thoracic• Urology• Ortho• ENT• Interventional• etc
MAS & Ambulatory Surgery
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Dr M G Bhat30/03/2014, Gokak
Stand Alone
Day Care Surgical Centers
Part of a Multi
Specialty Hospital
Hospital
Only Few in India
• Good Infrastructure• 25-30 beds• 4 OR• HDU• Prepared to shift if required
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Dr M G Bhat30/03/2014, Gokak
Procedure <12hr 24 24-48 72
Lap Chole 236 210 24 2
Ing Hernia 110 98 12
Inc Hernia 36 3 27 2 4
Sleeve Resection
41 39 2
Appendix 7 4 3
Diagnostic Lap 6 6
Colorectal 6 2 4
Fundoplication 4 4
Gastric 4 2 2
Hellers 2 2
Spleen 1 1
Total 453 321 74 46 12
Personal Series: Lap in Nova Specialty Hospitals: 2010-13
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*
Clinical outcomes Metric
Same day discharge ~60%
Superficial Post-Surgical Infections
0.035%
Transfer to Other Hospital (for observation)
0.12% (31 nos.)
Fatalities* 0.01% (3 nos.)
Clinical outcomesUrology, 1598, 5%
ENT, 4349, 14%
General Surgery, 11280, 37%Gynaecology, 4039,
13%
Opthomology, 1739, 6%
Orthopedics, 5100, 17%
Plastic surgery, 1233, 4%
Same day discharge (<24
Hrs)
24-48 Hrs discharge
Beyond 48 Hrs discharge
15%
25%
60%
Nova Audit : 2009-2013 : >30,000 Surgeries
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Dr M G Bhat
Technical Consideration
30/03/2014, Gokak
• Preop Motivation and Planning• Anesthesia ( Quick Recovery)• Analgesia• No Sedation• PONV (Post op nausea and vomiting)• Early Ambulation• Early Feeds• Passing Urine• Encouragement • If all OK Discharge
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Dr M G Bhat30/03/2014, Gokak
Technical ConsiderationSensorcaine
Infiltration into woundInstillation in Peritoneum
Abdominal Support in Incisional Hernias
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Dr M G Bhat
Financials
30/03/2014, Gokak
1. Package Rate Uniformity Transparent
2. Professional Fee
3. Insurance Acceptance
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Dr M G Bhat
Advantage:
30/03/2014, Gokak
Early Discharge Recovery at HomeReturn to work
Ease and Convenient
Cost Saving
Less of INFECTION
Surgeons Comfort
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Dr M G Bhat
Disadvantage
30/03/2014, Gokak
Surgeon MindsetAcceptance
ComplicationsGeneralSpecific to surgery
Need for Shifting to Tertiary Care?
Return to center
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Dr M G Bhat30/03/2014, Gokak
Consultant SurgeonNova Specialty Surgery Hospital, BangaloreMedical Director, Nova Medical Centers Ltd, India
Thank you
Dr. M G BhatMS, FRCS(England & Edinburgh), FICS, DMLE (Law), DMIRCSEd (Informatics)