Laparoscopic Day Surgery: The

American Experience

Alfons Pomp, MD, FACS

Weill Medical College of Cornell
University

CHUM Hotel-Dieu Montreal

Ambulatory/Day Surgery
Same

day discharge (< 23 hour stay)

Physician office, ambulatory surgical centers
(ASC) and hospital based outpatient
1990s American Hospital Insurance Programs
looked at risk/benefit of the economics
Standard of caresafe outcomes?
Nonetheless 60-70% operations are performed as
outpatient procedures

Weill Cornell NYP Hospital

Mandate: The American

Experience
Ambulatory

Surgery (hernia/cholecystectomy)
Reflux surgery
Bariatrics
-Banding
-Gastric bypass
Surgery of increasing complexity in more fragile
patients

What is the risk

of having an operation
No one really knows
Netherlands (Arbous et al 2001) 800,000 pts
8.8/10,000 mortality (1.4 due to anesthesia)
USA (Fleisher et al 2004) 564,267 Medicare
procedures; 7 day mortality rates
4.1/10,000;

Operative Risks
data taken from inpatient procedures
Associated

with patient factors

Associated with anesthesia
Associated with the surgical procedure
Associated with doing the procedure as
ambulatory/day surgery

Patient Factors: Age

Age

(>65 years)
adverse intra-op events/not post-op events
hypertension: intra-op cardiovascular events
unanticipated readmission rates
Age (85 years)
co-morbidity, hospitalization < 6 months

Patient Factors
Hyper-reactive

airway disease
(asthma, COPD, smoking)
Coronary artery disease(IHD, MI, CHF,BP)
Obesity
Obstructive sleep apnea
Diabetes

Diabetes
80%

type II/ 80% are obese: associated with

increase in unplanned admissions
Poor control associated with increased rate
of surgical complications

Diabetes
Understand

disease/ measure BS at home

Treatment of hypoglycemia
No recurrent admission with complications
related to diabetes
Hb1Ac >8 unsuitable > 9 not any elective
surgery
Metformin associated with lactic acidosis

American Society of
Anesthesia (ASA) Class
Class

1 Healthy patient, no medical problems

Class 2 Mild systemic disease
Class 3 Severe systemic disease, but not
incapacitating
Class 4 Severe systemic disease that is a constant
threat to life
Class 5 Moribund, not expected to live 24 hours
irrespective of operation
An e is added to designate an emergency operation.

Anesthesia
analgesia/amnesia/paralysis
Anxiety
Pain

afferent, inflammation
Consciousness
Autonomic stimulation
Memory
Movement

PONV
(Post-anesthesia nausea/vomiting)
Common cause of unplanned admissions
Risk factors
intra-peritoneal gas
bowel manipulation
female gender
history of motion sickness
opiates

PONV Prevention
Pre-induction

anti-emetics
Short term induction anesthetics
Volatile anesthetics (sevoflurane)
Short acting muscle relaxants
Analgesia
portals, intra-peritoneal spray
NSAIDS/ketorolac

Post-anesthesia Discharge
Scoring System
Vital

signs
Activity level
Nausea and vomiting
Pain
Surgical care

Are ambulatory risks higher

than inpatient?
5-8%

of procedures are performed in MDs

office w/o federal regulations, moderate
rates of readmission
ASC have lowest adverse outcome
Highest rates of readmission and deaths are
surgeries performed as outpatient in hospital
setting

Ambulatory Surgery Risk

Factors
ASA class
Advanced

age (> 85 years)

Inpatient admission history
Surgical procedure complexity (time)
Medical causes account for less than 20% of
admissions

Ambulatory Surgery Risk

Factors
Hyper-reactive

airway disease (smoking)

Coronary artery disease (functional)
Diabetes
Obesity
Obstructive sleep apnea

Ambulatory Surgery
90

minutes/6 hour recovery time

Reflux operations -Nissen
Bariatric operations-Banding
90 minutes/23 hour discharge time
Bariatric operations-LRYGBP

Day Case Laparoscopic

Nissen Fundoplication
Patient

selection
Anesthesia protocols
Discharge rates and time
Postoperative complications/re-admissions

Ng et al ANZ J Surg 2005

Nissen Fundoplication
ASA grade

I-II (patient bias selection)

30 minute drive from the hospital
Obesity
Asthma
Age

Nissen Fundoplication
Pre-emptive

analgesia
Anti-emetics
Propofol as induction, variable maintenance
Local anesthesia in the wounds
Post-operative

reviews

Nissen Fundoplication
>

90% discharge rate most studies 6-7 hrs

cardiovascular stability
clear fluids
adequate pain control
able to ambulate

Nissen Fundoplication
1-11%

re-admission rate
dysphagia/inability to tolerate fluid
comparable to hospitalized patients
86% patients have resolution of symptoms
1.5-3 days US $2500-3400/case

Bariatric Explosion
Epidemic

of obesity
Laparoscopic approach
Publicity / media
Patient demand

Schirmer, B. Watts, S.H. Laparoscopic Bariatric

Surgery Surg Endosc 2003

Bariatric Surgery-USA
1994-1999
2000
2001
2002
2003
2004

10-15,000/year
22,000
48,000
75,000
105,000
140,000
(450,000 lap cholecystectomies)

Schirmer B., Watts S.H., Surg Endosc 2003

Surgery for Obesity

WLS

today

Restriction
Malabsorption

operations
- Lap band
Sleeve gastrectomy
Gastric bypass
Duodenal Switch

Surgical Procedures:

Laparoscopic Adjustable Gastric

Banding
Inflatable

gastric band
just distal to G-E
junction
Purely restrictive
procedure
Reversible
Technically simple

Gastric Banding
343

patients 4/2003-1/2005
Contra-indications
cardiac co-morbidity
pulmonary co-morbidity
poorly controlled diabetes ( + all > 60)
anticoagulation
impaired mobility
Watkins B. M. et al Obesity Surgery 2005

Gastric banding
4.5

13.5kg pre-op weight loss

DVT prophylaxis
Anesthesia
scopolamine/IV rantidine/ondansetron
local bupivacaine/ketorolac/dexamethasone
liquid hydrocodone/acetaminophen

Gastric banding
305

females/38 males 43.5 years/BMI 44.5

OR 53 minutes
8.2 % paid by insurance company
10 complications
5 occlusions treated medically
colon perforation
3 transfers to hospital

Roux-en-Y Gastric Bypass

15-30 cc
Pouch
100-150 cm
Roux limb

Gastric bypass
2000

patients LRYGBP 10/2001-12/2004

Average BMI 49
Female to male ratio 7:1
OR times 54-115 minutes average
1669 (84%) discharged within 23 hours
McCarty T.M. et al Annals of Surgery 2005

Gastric bypass
Early

complications (<30 days)

stricture , bleeding, leaks, PE
(0.8%,0.3%,0.2%,0.1%)
Late complications
internal hernias, stricture, G-G fistula
(2.5%,1.3%,0.2%)
2 mortalities: hemorrhage /sepsis

Gastric bypass
Predictive

of discharge
surgeon experience (>50 cases)
patient age (<56)
BMI <60
weight < 400 lbs (180 kg)
co-morbidities < 4
intra-operative steroid bolus

Gastric bypass
Lessons

learned
KEEP RATE OF COMPLICATIONS LOW
Circular stapler 25mm/ Linear Stapler
Staple buttress
Internal hernias less with ante-colic
approach
Intra-operative steroids

Gastric bypass
National

Hospital Discharge Survey

10% complication rate
LOS 7 days
Variability: open procedure, clinical care
pathways to reduce pain, nausea, narcotic
requirements and complications
Livingston E.H. Am J Surg 2004

Laparoscopic Day surgery for

Liver Resection
17

patients, no conversions 2002-2004

Anterior and medial segments of the liver
Tissuelink, GIA stapler, intra-op U/S
11 patients averaged 14 hours stay
5 segmentectomies
OP time 174 minutes

 Decreased

pain and wound related

morbidity
Short hospital stay in appropriate patients
(lower ASA scores)
Learn P. et al J Gastrointestinal Surgery 2006

Successful discharge

meticulous surgery, low complication rate

Post-operative pain and nausea
Pre-operative analgesia
Anti-emetics
Standardized anesthesia protocols
short acting agents

Successful Discharge
Information

prior to the procedure

Written instructions on discharge
Home contact
monitor progress, reassure
detect early problems
Self referral to surgical team-minimal delay

Conclusions
Attractive

to the surgeon
reduce waiting times
decreases cancellations due to bed shortage
COST-EFFECTIVE
Attractive to the patient?
PONV, pain, anxiety (help) addressed

Un grazie
(di cuore)

Alfons Pomp, MD, FACS