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)

Dr M G Bhat

Ambulatory Laparoscopi

c Surgery

30/03/2014, Gokak

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

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

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

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

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.

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

Dr M G Bhat

Pre Operative

30/03/2014, Gokak

• Clinical Evaluation• Investigations• Assessment• Planning• Suitability• Motivating• Financials • Fix Date of Surgery

Dr M G Bhat

Operation – Surgery Day

30/03/2014, Gokak

• Admission in the morning (patient comes prepared)

• Early Surgery ( No Waiting)

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

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

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

*

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

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

Dr M G Bhat30/03/2014, Gokak

Technical ConsiderationSensorcaine

Infiltration into woundInstillation in Peritoneum

Abdominal Support in Incisional Hernias

Dr M G Bhat

Financials

30/03/2014, Gokak

1. Package Rate Uniformity Transparent

2. Professional Fee

3. Insurance Acceptance

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

Dr M G Bhat

Disadvantage

30/03/2014, Gokak

Surgeon MindsetAcceptance

ComplicationsGeneralSpecific to surgery

Need for Shifting to Tertiary Care?

Return to center

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)