Laparoscopic diagnosis and repair of asymptomatic bilateral inguinal hernias

The clinical implications of occult inguinal hernia identified during laparoscopic peritoneal dialysis catheter insertion

BACKGROUND

Occult inguinal hernias predispose patients undergoing peritoneal dialysis (PD) to symptomatic inguinal hernia formation causing complications. We conducted a retrospective study to assess the usefulness of routine laparoscopic examination for occult inguinal hernia during PD catheter insertion and the risk profile of occult inguinal hernia according to hernia classification in patients with PD.

METHODS

This study included 79 patients who underwent initial laparoscopic PD catheter insertion between 2021 and 2022. An occult hernia was defined as an internal hernial sac of all sizes that was not detectable on physical examination. The European Hernia Society groin hernia classification was used to describe the hernia type. We investigated the association between event-free survival and occult inguinal hernias in patients undergoing PD.

RESULTS

Occult inguinal hernias were diagnosed in 24 (32%) patients. Among these patients, 5 (21%) patients underwent metachronous repair. In patients with L2 occult hernias, the cumulative incidence rates of right and left symptomatic hernias within one year were 100% and 50%, respectively. Multivariate analysis revealed that L2 occult hernias were associated with metachronous hernia repair.

CONCLUSION

The L2 occult inguinal hernia during PD was associated with metachronous repair, suggesting the importance of routine examination of inguinal hernias during laparoscopic PD catheter insertion.

Comparison of bilateral to unilateral total extra-peritoneal (TEP) inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

Laparoscopic herniorrhaphy (LH) has become the treatment of choice in many centers for patients with inguinal hernia (IH). Our aim was to compare the morbidity outcomes of bilateral vs unilateral IH repair using the laparoscopic total extra-peritoneal (TEP) technique, to determine whether undertaking bilateral IH repair places patients at additional risk.

METHODS

Manuscripts published up to the end of 2021 on PubMed/MEDLINE, EMBASE, Cochrane Library, Scopus, and Web of Science were searched. Patients (> 16 years) undergoing a primary elective unilateral or bilateral TEP operation, using the standard 3-port laparoscopic technique, were identified. Quality of evidence was assessed using the GRADE criteria. Meta-analysis was conducted where possible. Where this was not possible, vote counting was conducted using effect direction plots.

RESULTS

Eight observational studies, with a total of 18,153 patients were included. Operative time was significantly longer for bilateral operations. There was no significant difference in conversion to open, post-operative seroma, urinary retention, haematoma, and length of hospital stay. There was an increased rate of hernia recurrence in patients undergoing bilateral IH repair.

CONCLUSION

Although limited by the observational nature of the included studies, there is no conclusive evidence to suggest a differential burden of morbidity between unilateral and bilateral TEP IH repair. As all included papers are from observational studies only, evidence from all outcomes is at best very low quality. This manuscript thereby highlights a need for randomized controlled trials to be conducted in this area.

A study of the effectiveness of the bilateral and contralateral occult inguinal hernia repair by total extraperitoneal repair with intraperitoneal examination

PURPOSE

Of the various methods used, the laparoscopic surgical repair of inguinal hernias is widely performed. We aimed to estimate the incidence of bilateral and contralateral occult inguinal hernias in our surgical population and to compare the results of total extraperitoneal repair (TEP) for bilateral and unilateral inguinal hernias, occult and non-occult hernias.

METHODS

We retrospectively reviewed data of patients who underwent TEP for the repair of adult inguinal hernias from January 2012 to November 2018 in our hospital.

RESULTS

Of the data of 259 patients included, 134 (51.7%) and 125 (48.3%) had unilateral and bilateral inguinal hernias, respectively, while 70 patients (27%) were found to have a contralateral occult inguinal hernia, intraoperatively. The mean operative time was 129 ± 48 minutes (range, 43-300 minutes) and 167 ± 55 minutes (range, 85-390 minutes) for the unilateral and bilateral groups, respectively, indicating a significantly longer duration of surgery for the bilateral group (P < .05). Recurrence occurred in 1.5% (5/134) and 0.4% (1/250) of the operated hernias in the unilateral and the bilateral groups, respectively, indicating a significantly lower rate of recurrence in the latter group (P < .05). The two groups showed no statistically significant differences with respect to the remaining perioperative data. The incidence of postoperative complications in occult hernias was not significantly different from that in non-occult hernias.

CONCLUSIONS

Our TEP method, involving a laparoscopic exploration from the intraperitoneal side, can be safely and effectively utilized for the repair of both bilateral and contralateral occult inguinal hernias.

Asymptomatic contralateral inguinal and ventral hernias among people with a workers' compensation claim for hernia

STUDY AIM

There is a gap in evidence that demonstrates an increased risk of hernia formation in laborers. A notable incidence of a second asymptomatic hernia among people making a workers' compensation claim for a hernia would suggest that the pathology is not acute and probably not related to work, or the performance of a single strenuous event.

PATIENTS AND METHODS

We performed a retrospective database study of a consecutive sample of 106 adults who claimed a work-related abdominal hernia between September 2016 and December 2018 and had a Computed Tomography (CT) scan as part of a diagnostic workup. Hernias were classified as incidental if patients had a contralateral inguinal hernia with unilateral groin symptoms, or if patients had a ventral hernia with only groin symptoms or vice versa.

RESULTS

Thirty-three percent of patients had an incidental hernia. No patient factors were associated with having an incidental hernia. Higher BMI and having a concurrent incidental hernia were associated with lower odds of surgical treatment under the injury claim.

CONCLUSION

Abdominal symptoms after a work event might lead to a diagnosis of hernia, and there is a notable likelihood that the hernia is incidental and unrelated to work. New symptoms at or near the site of an abdominal hernia may or may not be from the hernia, and very often are more consistent with an abdominal muscle strain. The clinical or imaging finding of an abdominal wall defect or the presence of a hernia may be incidental, unrelated to the physical activity.

Should surgeons repair symptomatic, clinically occult, radiologically evident, inguinal hernias? A case-control study of patient-reported outcomes

INTRODUCTION

Patients who present with symptomatic, clinically occult, radiologically evident (SCORE) inguinal hernia represent diagnostic and therapeutic challenge with a wide differential diagnosis of groin pain. Often, diagnosis leads to surgical intervention despite the lack of evidence supporting this practice. This study evaluates patient-reported outcomes following surgical or conservative management of SCORE inguinal hernia.

METHODS

Single-centre retrospective review of radiology database and general surgery outpatient booking system between 2017 and 2018 to identify SCORE hernia patients. Notes review to identify surgical and conservative management groups. Patient-reported outcomes determined using the validated EuraHS-QOL tool. Surveys sent to patients via post with follow-up telephone conversations between October 2019 and June 2020. Replies from the conservative and operative cohorts were compared.

RESULTS

Total of 76 patients identified. 63 (83%) replies received and analysed (10 did not answer, 2 declined, 1 deceased). 32 in the surgical cohort and 31 in conservative management cohort. No statistically significant difference was there between cohorts in age, BMI, ASA, Charlson Comorbidity Index. No statistically significant difference was there in pain at the site of hernia (p = 0.535); restrictions of activities (p = 0.406); cosmetic discomfort (p = 0.289) in patient-reported outcomes between surgical and conservative cohorts.

CONCLUSION

There is no difference in pain, restriction to function or cosmesis in symptomatic clinically occult, radiologically evident inguinal hernia patients following either surgical or conservative management. A clear definition and further studies are essential to deliver better care for this population of patients.

Comparing the Incidences of Occult Contralateral Hernia under Laparo-Endoscopic Techniques and of Contralateral Metachronous Hernia after a Unilateral Groin Hernia Repair in Open Technique

The aim of this study was to evaluate the utility of immediate repair of a contralateral occult hernia at the same time as incipient hernia repair. A total of 693 patients were diagnosed preoperatively with a unilateral groin hernia from January 2006 to December 2017. The open technique was used for 541 patients, and the laparo-endoscopic technique was used for 152 patients. The incidences of occult contralateral hernia confirmed during surgery under laparo-endoscopic techniques and those of contralateral metachronous hernia after a unilateral groin hernia repair with open technique were compared. Fifty-one (9.4%) of 541 patients underwent a contralateral metachronous hernia repair after unilateral groin hernia repair. Twenty-three (15.1%) of 152 patients had occult contralateral hernias using laparo-endoscopic techniques. There was a significant difference in the incidence of contralateral metachronous hernia and that of occult contralateral hernia (P = 0.02). It is concluded that finding and repairing an occult contralateral hernia at the time of laparoendoscopic technique has the advantage of avoiding a second operation. However, it has been considered overtreatment to repair all patients with an occult contralateral hernia.

Impact of age on groin hernia profiles observed during laparoscopic transabdominal preperitoneal hernia repair

BACKGROUND

How increasing age affects the characteristics of groin hernia remains uncertain. This study evaluated the association between age and the type of groin hernia, especially with respect to its multiplicity, observed during laparoscopic transabdominal preperitoneal (TAPP) hernia repair.

METHODS

We retrospectively evaluated 634 consecutive patients with primary groin hernia who underwent laparoscopic TAPP repair between October 2000 and June 2017. Patients were stratified into 4 age groups: < 60 years, 60-69 years, 70-79 years, and 80 years or older.

RESULTS

The incidence of occult contralateral hernia and multiple ipsilateral hernias increased significantly with each increasing age group: 7.3%, 10.4%, 12.7%, and 20.8% for occult contralateral hernia (p = 0.005), and 5.6%, 9.2%, 16.8%, and 21.7% for multiple ipsilateral hernias (p < 0.001), respectively. Univariate analyses showed that an older age (age ≥ 70 years) was the only factor significantly associated with the presence of multiple groin hernias (odds ratio, 2.69; 95% confidence interval, 1.89-3.81; p < 0.001). In patients with multiple ipsilateral hernias, the prevalent form in men was a pantaloons hernia, with an incidence of about 70% across all age groups, whereas in women it was groin hernias, with one component being a femoral hernia, an obturator hernia, or both.

CONCLUSIONS

The multiple occurrence of groin hernias, either unilaterally or bilaterally, was a clinical feature in the elderly.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Early results of dual approach hernioplasty (DAH): an innovative laparoscopic inguinal hernioplasty technique

BACKGROUND

In this study, the proposed technique is combining the invented method of extraperitoneal dissection utilizing gas insufflation through Veress needle introduced from the groin with the transabdominal approach. Such a combination minimizes operative demands, achieves major goals, and reduce operative time in an attempt to improve laparoscopic hernioplasty techniques.

METHODS

The study recruited 211 patients having primary reducible inguinal hernia upon first diagnosis. Abdominal ultrasound examination achieved to exclude any additional pathology and confirming clinical diagnosis. The new technique is applied on all patients without any modification through the whole series.

RESULTS

Patients' epidemiology, operative characteristics, and follow-up are all tabulated. Results showed no complications nor conversion to open procedure.

CONCLUSIONS

The proposed procedure showed preliminary encouraging results regarding technique, clinical outcome, time-saving, and patients' safety. Combination of extraperitoneal gas-derived dissection, transabdominal field review, and preperitoneal mesh application offers an innovative and promising laparoscopic hernioplasty technique. The study is introducing the technique and as well invites further trials on wider scale to verify the technique.

Advantages of laparoscopic transabdominal preperitoneal herniorrhaphy in the evaluation and management of inguinal hernias

BACKGROUND

Laparoscopic transabdominal preperitoneal (TAPP) herniorrhaphy provides an opportunity to definitively evaluate both inguinal areas without the need for additional dissection. We aimed to establish the rates and contributing patient factors to errors in the preoperative assessment.

METHODS

A retrospective review of consecutive patients undergoing laparoscopic TAPP herniorrhaphy at 2 tertiary-care centers. Preoperative history and physical examination were used to classify the presence of hernia as "definite," "questionable," or "negative." Any discrepancies between preoperative and intraoperative findings were viewed as errors in preoperative assessment.

RESULTS

Two hundred sixty-two patients underwent 328 laparoscopic TAPP hernia repairs. Of the 283 hernias diagnosed as "definite" preoperatively, 276 were confirmed at operation (97.8%). An additional 19 of 173 (11.0%) clinically unrecognized hernias were repaired at the time of surgery. Overall, our approach avoided unnecessary groin explorations and/or repairs in up to 16.4% patients and may have prevented inappropriate delays of herniorrhaphy in up to 19.8% of patients. The sensitivity, specificity, and positive predictive value of the clinical assessment of inguinal hernia were 94.5%, 80%, and 88.9%, respectively. Symptom and/or examination findings of inguinal mass were the only significant independent predictor of accuracy (P < .001).

CONCLUSION

A high rate of discordance exists between the preoperative clinical assessment and true presence of inguinal hernias. Given the unique ability of laparoscopy to accurately evaluate the contralateral side and the limited added morbidity of bilateral repair, TAPP herniorrhaphy is beneficial in avoiding unnecessary explorations and allowing timely repairs in patients with occult inguinal hernias.

Incidence of occult inguinal and spigelian hernias during laparoscopy of other reasons

BACKGROUND

A true incidence of occult inguinal and Spigelian hernias in adult population is unknown. The frequency of incipient hernias was studied during laparoscopy of other abdominal diseases.

METHODS

The 201 laparoscopic procedures included 104 cholecystectomies, 55 fundoplications, 36 diagnostic, and 6 miscellaneous operations. There were 133 females and 68 males with a mean age of 53 +/- 14 years. The orifices of all inguinal and Spigelian hernias were carefully recorded at the beginning of laparoscopy by using 30 degrees optic.

RESULTS

The overall frequency of unexpected hernias was 43 of 201 (21%) including 36 (18%) inguinal hernias, 5 (2%) Spigelian hernias and 2 (1%) ventral hernias. The number of hernias was higher in males than in females (P = .003). The most common finding was indirect inguinal hernia in 27 (13%) subjects. Usually hernia orifices were insignificant and only 5 of 201 laparoscopic hernioplasties were undertaken without any complications.

CONCLUSIONS

Occult hernia orifices are commonly found in laparoscopic operation. Usually the defects are asymptomatic and hernioplasty is not needed. Herniation of Spigelian fascia is rare (<2%) in adults during laparoscopy.

Laparoscopic repair for groin hernias

So where do things stand in 2003? Laparoscopic herniorrhaphy appears to result in less postoperative pain (acute and chronic) and in a shorter convalescence and an earlier return to work, compared with the open repair. It can be performed safely and with a low recurrence rate. However, it takes longer to do, is more difficult to learn, and costs more, all reasons why it is not more commonly performed. Currently, laparoscopic herniorrhaphy accounts for 15% to 20% of hernia operations in America and around the world. Who can blame the surgeon in a community practice for opting for the open mesh repair, operating on familiar anatomy, and using familiar techniques? Nevertheless, with efforts to cut costs by eliminating disposable equipment and honing skills to decrease operating time, laparoscopic herniorrhaphy will probably continue to be a contender, especially for the younger patient who wants to return to work quickly and for patients with bilateral and recurrent hernias. It is arguable that surgeons should possess skill in both open and laparoscopic techniques and should know the indications for each--some hernias are best repaired laparoscopically. That said, laparoscopic herniorrhaphy will most likely be performed by those with a special interest and proficiency in the technique. At the least, the laparoscopic revolution and laparoscopic hernia repair have helped elevate the study of hernia anatomy and herniorrhaphy to a position it deserves and this has made us all better hernia surgeons. What was once the stepchild of general surgery now occupies a more prominent and respectable place. With the continuing efforts of dedicated, energetic investigators, we should continue to see advances in the safe and effective repair of this most common of surgical maladies.

A comparative outcome analysis of bilateral versus unilateral endoscopic extraperitoneal inguinal hernioplastics

BACKGROUND

Bilateral inguinal hernia is an accepted indication for endoscopic totally extraperitoneal inguinal hernioplasty (TEP), but few studies have proved that the outcomes of bilateral TEP are as good as those of unilateral TEP. The objective of the present study was to compare the clinical outcomes of patients who underwent unilateral TEP with those of patients who underwent bilateral TEP.

PATIENTS AND METHODS

From June 1999 to May 2002, 103 patients underwent simultaneous bilateral TEP. The clinical data and outcomes of these patients were compared with those of an agematched cohort of patients who underwent unilateral TEP during the same period.

RESULTS

The demographic features and hernia types were similar for the two groups. The incidence of direct inguinal hernia was significantly higher in the patients with bilateral inguinal hernia. The mean operative time for unilateral TEP was 65 minutes, and for bilateral TEP it was 97 minutes. The mean pain score at rest was significantly lower in the bilateral group than in the unilateral group on postoperative days 2 and 3. Pain scores at rest and during coughing from the day of operation to day 6 were otherwise comparable for the two groups. Comparisons of postoperative morbidity, length of hospital stay, and time to resumption of normal outdoor activities showed no significant differences between the two groups.

CONCLUSIONS

The postoperative recovery and morbidity of patients who underwent bilateral TEP were equivalent to those who underwent unilateral TEP. Simultaneous bilateral TEP is safe and advantageous in patients with from bilateral inguinal hernias.

Ambulatory surgery: an overview

PURPOSE OF REVIEW

Ambulatory surgery is now one of the major areas of surgical and anesthetic practice, with up to 70% of procedures performed in the ambulatory setting. This review focuses on some of the recent studies performed in day case anesthesia.

RECENT FINDINGS

Emphasizing the economic benefits of ambulatory surgery, investigators have studied the cost implications of various anesthetic techniques and their impact on patient recovery, discharge times and readmission rates. Quality anesthetic management measures such as mortality, morbidity, postoperative stay and patient satisfaction ensure that perioperative care and treatment are optimized.

SUMMARY

Careful patient selection can minimize perioperative events. The concept of multimodal analgesic and antiemetic therapy, in combination with newer anesthetic drugs, help expand the field of ambulatory surgery.