What types of surgical procedures are appropriate for ambulatory surgery?
Initially, it was believed that procedures should be limited to those that could be easily accomplished within 1–11/2 hours. This was based on the premise that recovery time would be significantly prolonged after the administration of a lengthy general anesthetic and would perhaps prevent discharge. However, it has been well demonstrated that patients may be discharged safely and on a timely basis even after long operations performed with general anesthesia.
The types of surgical procedures that may be performed on an ambulatory basis will depend on whether an ambu-latory surgery facility is truly a freestanding unit (geo-graphically detached from a hospital) or is located within a hospital, or directly contiguous to an inpatient facility. Hospital-based units often accept patients with a greater severity of baseline illness and may perform more complex surgical procedures for a number of reasons. In the event of an unexpected massive surgical hemorrhage, availability of immediate blood bank support is crucial. However, when the need for blood may be anticipated preoperatively, even freestanding ambulatory surgery centers can arrange for blood products to be available, and transfusions may be administered if the need arises. Patients may also be asked to donate one or more units of autologous blood, which may be kept available for either intraoperative or postoperative use. Procedures in which blood might be administered include extensive liposuction or reduction mammoplasty. Radiology services, as well as subspecialty consultative services and the relative ease of hospital transfer for overnight admission, allow performance of more involved and invasive procedures in hospital-based ambulatory surgical facilities.
Ideal procedures for ambulatory surgery result in relatively minor postoperative physiologic changes including fluid shifts and blood loss. Commonly performed surgeries include procedures from all surgical disciplines and subspe-cialties. A few examples include cataract extraction, minor breast surgery, plastic surgery, dilatation and curettage, hysteroscopy, termination of pregnancy, laparoscopy, arthro-scopy, inguinal and umbilical herniorrhaphies. The common denominator of all the procedures is that they are associated with only mild-to-moderate degrees of postoperative pain, which may be readily controlled by oral analgesic agents.
In the early days of ambulatory surgery, tonsillectomy was an example of a procedure that was considered to require overnight in-hospital observation. Today, it is being per-formed on an ambulatory basis in many centers, although the period of postoperative observation is increased compared with that for other ambulatory surgeries. After tonsillectomy, nausea and vomiting are the most common complications causing morbidity. Early bleeding, if it occurs, usually becomes evident within the first 6 hours. Therefore, it is now considered safe to discharge individu-als to home who are otherwise in good health and reside within a reasonable distance from the facility with respon-sible adults. It is especially important that adequate fluid repletion be accomplished before discharge because early attempts at fluid intake after tonsillectomy may be rela-tively unsuccessful as a result of marked pharyngeal pain.