Poli.Chir. Ambulatory proctology Bruno Roche Unit of Proctology University Hospital of Geneva...
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Transcript of Poli.Chir. Ambulatory proctology Bruno Roche Unit of Proctology University Hospital of Geneva...
Poli.Chir.
Ambulatory proctology
Bruno Roche
Unit of Proctology
University Hospital of Geneva
www.proctology.ch
Poli.Chir.
Advantages
Life minimally disturbedAnxiety reducedLess nosocomial infectionsEarlier return to activitiesWork time off reduced
Poli.Chir.
Advantages
Administrative management Costs of outpatient < inpatient Overall health expenditure reducedHospital beds for severe cases
Poli.Chir.
Disadvantages
Preoperative instructionsPreoperative preparation difficultiesTransportation problemsAssistance at homeNecessity of resuscitative back-upAnalgesia management
Poli.Chir.
Selection criteria: Medical
Age (no more)ASA I and ASA II (no more)Medical condition controlledNo anti-aggregate medication
Poli.Chir.
Selection criteria: Social
Positive for outpatient surgeryNot alone during 24 hoursSocial circumstances adaptedEasy access to a bathroom and toiletsTelephone should be accessible
Poli.Chir.
Selection criteria: General
Not drive to go home
Distance home hospital:
60 to 100 km
Transportation facilities
Poli.Chir.
Selection criteria: Physician
Emergency accessible 24 hours a day
Poli.Chir.
Anesthesia
Local anesthesiaPosterior perineal block
Caudal or rachianesthesiaGeneral anesthesia
Short duration Low side effects
Poli.Chir.
Goals:- Deep and long-lasting analgesia - Relaxation of the anal canal- Blood-free operative field- No side effects on the bladder- Suppression of vagal reflex- Easy use in outpatients
Poli.Chir.
Local anesthaesia and perineal block:
60 ml 0.5% lidocaine + epinephrine12 ml Natrium Bicarbonate 8,4 %
Poli.Chir.
Practical organisation Practical organisation
No starving
No bowel preparation
No depilation
Premedication only for anxious people
Empty bladder and rectum pre-op
No venous access for LA and PPB
Resuscitation material in the room
Poli.Chir.
Poli.Chir.
Practical organisation
The patients receives
- Instructions
postoperative care
- Prescription
- Appointment for day 5
Time needed:
60 to 90 minutes
Poli.Chir.
Postoperative management
Sit Baths Shower: 3 - 6 x / DTopical wound healing cream:
MitosylPanthenolIalugen-Plus
Poli.Chir.
Postoperative management
Laxatives: MucillageMineral oilDuphalac
Anti-inflammatory drugsPainkillers
Poli.Chir.
Postoperative control
On day 5 WeeklyAs necessary
No routine digital examination Silver Nitrate if granulation
Poli.Chir.
Possible procedures:
Thrombosed haemorroidectomyHaemorroidectomySphincterotomyAbscess drainageFistulectomySliding flapsAnoplastyAnal warts excisionLow located villous adenomaSinus pilonidalis
Poli.Chir.
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Patients
1978 1982 1986 1990 1994 1998 2002
Années
Iinterventions proctologiques ambulatoires1978 à 2004
Iinterventionsproctologiquesambulatoires
Poli.Chir.
Ambulatory procedure in L.A. 1993 to 2004
RECOVERED AMBULATORY
Haemorrhoids 887 1042
Fissures 46 545
Fistulas 331 686
Pylonidal Sinus 16 786
Condyloma 37 289
Tumours, polypes 49 175
Anoplasty 17 20
Others 24 182
Total 1407 3725
Poli.Chir.
COMPLICATIONS OF 3725 PROCEDURES
Bleeding (18)
4 post fistulectomy8 post pylonidal sinus 5 post haemorrhoïdectomy1 post sphincterotomy
Infections 0
Fecaloma 3
Urinary Retention 5
Hospitalisation 17
Poli.Chir.
Can we prevent postoperative complications
Pain ?
Bleeding ?
Bladder Retention ?
Fecal Impaction ?
Poli.Chir.
Postoperative pain control
We can’t determine preoperatively Tolerance of postoperative pain Sensitive person
We should routinely :Infiltration long lasting ALStrong painkillers
Poli.Chir.
Pre-emptive analgesia in post operative pain controlPre-emptive analgesia in post operative pain control
Double blind randomised study Ropivacaïne vs. Placeboon 100 consecutive perineal surgery in general anaesthesia
VAS evolution in post-operative pain
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7
J1 J2 J3 J4 J5 J6 J7
Post op Days
VA
S 0
to
10
infiltration AL pré-op.
Sans infiltration AL
Poli.Chir.
Prevention of urinary retention
Operation with empty bladder
Restriction of fluid administration
Posterior Perineal Block < 0.5 %
Poli.Chir.
Prevention of faecal impaction
Preoperative dietHigh fibbers rate
PostoperativeParaffin oil dailyOsmotic laxatives one week
Poli.Chir.
FUTURE:
Quality control studies Evaluation the outcomesAssess patients satisfaction index
If patients are not happyindications will never be enlarged
Poli.Chir.
Operative indications enlarged
Rectoceles
Sphincteroplasty
Poli.Chir.
Better Proct. outpatient surgery:
Short anesthesia low of side effectsOperative indications increaseOvercome postoperative painStimulate wound healing
Poli.Chir.
Conclusions:
Proctological outpatient surgery can be performed in a safe way:- few complications- high patient satisfaction index
Poli.Chir.
Indications will be enlarged if:
General anesthesia shorter and saferLong lasting local anesthesiaBetter pain killersMore effective wound healing drugs
Poli.Chir.
Indications will be enlarged if:
Patient satisfaction index highStimulation from insurances