Author’s Accepted Manuscript

Ambulatory Pediatric Surgery

Andrew B. Nordin, Sohail R. Shah, Brian D.

www.elsevier.com/locate/sempedsurg

PII: S1055-8586(18)30003-9
DOI: https://doi.org/10.1053/j.sempedsurg.2018.02.003
Reference: YSPSU50734
To appear in: Seminars in Pediatric Surgery
Cite this article as: Andrew B. Nordin, Sohail R. Shah and Brian D. Kenney,
Ambulatory Pediatric Surgery, Seminars in Pediatric Surgery,
https://doi.org/10.1053/j.sempedsurg.2018.02.003
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Ambulatory Pediatric Surgery

Andrew B Nordin MD a,b, Sohail R Shah MD, MSHA c,d, Brian D Kenney MD, MPH a,e

a
Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children’s Drive,

Columbus, OH, 43205

St, Buffalo, NY, 14203

MS390 Houston, TX 77030

Address correspondence to:

Brian Kenney, MD

Nationwide Children’s Hospital

Department of Pediatric Surgery

700 Children’s Drive

Columbus, OH, 43205

Email: Brian.Kenney@nationwidechildrens.org

Phone: (614) 722-3439

Ambulatory pediatric surgery has become increasingly common in recent years, with

greater numbers of procedures being performed on an outpatient basis. This practice has clear

benefits for hospitals and healthcare providers, but patients and families also often prefer

outpatient surgery for a variety of reasons. However, maximizing the potential opportunities

requires critical attention to patient and procedure selection, as well as anesthetic choice. A

subset of outpatient procedures can be performed as single visit procedures, further simplifying

the process for families and providers.

Introduction

The performance of ambulatory surgery offers significant benefits for patients and their

families, as well as healthcare providers and the systems in which they practice. The growing

trend of increasing numbers of pediatric surgical operations to the outpatient arena is hardly a

new practice, and was first established at the Royal Glasgow Hospital for Children in 1909 due

to a lack of inpatient resources [1, 2]. The concept slowly gained traction over the following

decades, finally picking up steam in the 1960s with the development of the first outpatient

surgical center in 1968 [2]. In recent years, concerns over rising healthcare costs have stimulated

even further interest in broadening ambulatory surgical practices.

In exploring the topic of ambulatory pediatric surgery, this review will describe its

potential benefits, define the scope of appropriate surgical procedures and patient selection, and

highlight crucial anesthetic considerations. Special attention will be devoted to the practice of

single visit surgery, a practice which attempts to capitalize on and magnify the advantages of the
ambulatory surgery experience. Finally, practical considerations and advice from the literature

regarding the creation of new ambulatory practices will be reviewed.

Benefits of Outpatient Surgery

To the Patient and Family

While the shift of surgical procedures to the outpatient realm has advantages for both the

provider and the system in which he/she practices, the primary goal is to improve patient care.

By definition, outpatient surgery precludes the need for the patient to remain in the hospital,

thereby minimizing potential exposure to nosocomial pathogens and iatrogenic injuries [1].

Furthermore, patients and families often prefer more focused and personalized care that

minimizes time and distance away from the home [3]. In the ambulatory setting, wait times are

typically decreased both before and after surgery, with decreased stress and disruption for the

patient and their family [1]. Even among patients with appendicitis, same day discharge

following laparoscopic appendectomy correlates with greater postoperative patient satisfaction

[4]. Finally, minimizing time spent in a hospital away from home decreases any potential

economic impacts on the family such as lost wages, or payments for child care and transportation

[5]. In general, pediatric patients and their parents and family members prefer to recuperate at

home when possible. Equally importantly, several studies have demonstrated the safety of same-

day discharge after routine operations such as laparoscopic appendectomy and cholecystectomy,

with no increase in surgery-specific complications or unanticipated readmissions [6-8].

To the Provider

Based on the nature of the procedures typically performed in the outpatient setting,

providers are often able to accommodate up to 50-100% more cases within a set time period [9].
This increased efficiency can be attributed to a focus on streamlined throughput that permeates

the very concept of ambulatory surgery. Furthermore, moving these procedures out of an

inpatient operating room has the potential to relieve scheduling burdens, reserving larger, more

complex cases for inpatient operating room block time [9].

To the Healthcare System

Multiple studies have demonstrated that outpatient surgery reduces the costs of providing

surgical care as compared against inpatient surgery [2, 3, 9-11]. This reduction in cost can be

attributed primarily to a decrease in inpatient length of stay, but may also be related to a lower

risk of infection and decreased operating costs [9, 11].

Patient and Procedure Selection

Appropriate patient and procedure selection are paramount for patients and providers to

reap the full benefits of ambulatory surgery while minimizing the potential risk of any

complications. This begins with careful examination and evaluation of patients in the

preoperative clinic to ensure that appropriate cases are done in the outpatient setting. Each

hospital should develop its own criteria for outpatient cases, especially to exclude patients that

are not eligible. In addition, some patients are only considered for outpatient surgery after

preoperative clearance; these patients can be subdivided into those who can be cared for at the

free-standing surgery center and those whose operations should be performed at a surgery center

that is physically attached to the hospital.

In pediatric patients, one of the most important criteria is age: a combination of

gestational and post-natal age is utilized to determine the relative risk for apnea, and therefore

the need for continued monitoring, following general anesthesia. Specific age criteria vary by
institution, but otherwise healthy patients ranging from 50 to 60 weeks post conception are

generally eligible for ambulatory procedures [12]. Before this age, infants have higher risks of

apnea and other respiratory complications after undergoing general anesthesia. Full term infants

are typically candidates for outpatient surgery after 54 weeks post-conception age [12].

In addition to age, other specific aspects of the patient’s personal or family medical

history may preclude the safe performance of an outpatient surgical procedure. Patients with a

known difficult airway should not be treated in an ambulatory setting, in which the requisite

resources or expertise to manage such patients may be limited. Examples of airway concerns

include a history of prolonged intubation or ventilation, and patients with known tracheal

stenosis or airway malacia. Other respiratory diagnoses which may preclude the safe

performance of outpatient surgery include severe obstructive sleep apnea, dependence on

positive airway pressure or poorly controlled asthma [13].

Patients with certain chronic medical conditions such as poorly controlled diabetes

mellitus should not be cared for in an outpatient surgery center. Patients with a Body Mass

Index greater than the 95th percentile are considered obese and are not candidates for outpatient

surgery. Uncontrolled or new onset seizure patients are also excluded. Patients with congenital

heart disease (hypoplastic heart, septal defects, Eisenmenger syndrome, cyanosis, etc.) must be

repaired and stable prior to consideration for care in the outpatient surgery center. However, the

location of the ambulatory surgical center must be considered in these decisions, in that those

attached to adjacent inpatient facilities may be able to adequately manage medically complex

patients.

Certain patients may only be considered candidates for outpatient surgery after evaluation

and examination by anesthesiology (see Tobias paper on this topic in this issue of Seminars in
Pediatric Surgery). Included are patients with implantable devices, repaired congenital heart

defects and complicated medical histories, including a personal or family history of malignant

hyperthermia. Patients with malignant hyperthermia may safely undergo outpatient surgery, even

in stand-alone ambulatory centers, but anesthesiologists should prepare accordingly by flushing

the ventilator circuit of any volatile anesthetics [14]. Outpatient surgery centers should also be

prepared for the possibility of patients developing malignant hyperthermia for the first time. This

requires having an adequate and available supply of dantrolene, appropriate support staff, and

rapidly transferring the patient to an intensive care setting [14].Patients with an acute illness such

as upper respiratory or gastrointestinal infections should have a period of wellness prior to

surgery; recent hospitalizations or emergency room visits must be reviewed for cardiopulmonary

issues which may preclude an anesthetic. Patients with bleeding disorders should be reviewed to

ensure that their particular disorder will not pose a risk for outpatient surgery. Candidates with a

BMI >95% but below 99% may be eligible for outpatient surgery after review. Some

adenoidectomy patients under that age of two years may be eligible for outpatient surgery after

review. Craniofacial syndromes (Pierre-Robin, Trisomy 21, others) can at times pose airway

difficulties and must be reviewed. Finally, patients with recent vaccinations within one week of

surgery should be excluded. A case-by-case review by anesthesiology may help determine

whether patients who are not eligible for outpatient surgery at the free-standing surgery center

may be considered at centers attached to the main hospital.

The ideal procedure is one which can be rapidly performed, limiting the anesthetic time,

and with minimal risk of major complications. Examples of procedures commonly performed on

an outpatient basis include inguinal and umbilical hernia repairs, appendectomies,

cholecystectomies, tonsillectomies/adenoidectomies, circumcisions, and orchidopexies [7, 13,

detected by parents or other caregivers, precluding the need for prolonged inpatient observation.

In an effort to continue to enhance efficiency and decrease hospital length of stay, several

institutions have evaluated the safety of extending the types of procedures that may be treated

with ambulatory surgery. Two of the most commonly evaluated procedures in pediatric surgery

literature are laparoscopic appendectomy for simple appendicitis and laparoscopic

cholecystectomy. Several institutions have demonstrated that both laparoscopic appendectomy

for simple appendicitis and laparoscopic cholecystectomy can safely be performed as outpatient

procedures without overnight hospital observation [4, 17, 18]. Additional follow-up studies have

demonstrated no difference in 30-day hospital readmission rates or wound complications when

compared to 1 or 2-day hospital stays [6, 7]. The majority of studies demonstrating successful

implementation of a same-day discharge protocol discuss the need for a multidisciplinary effort

including nursing staff and providers across multiple hospital areas (emergency center, surgical

services, anesthesiology, and the post-anesthesia care unit). Additionally, a clear designation of

inclusion criteria (i.e., time of day, patient selection, diagnoses, and intra-operative findings)

should be disseminated and revisited through the implementation process. With appropriate

patient selection and process implementation these efforts also result in excellent patient and

provider satisfaction.

Given the many relative contraindications, it is clear that the outpatient surgery patients

represent a select group of the healthiest patients. The strict outpatient anesthetic criteria help

ensure that there will not be any need for conversion of a patient from the outpatient setting to

admission to the hospital.

Since a variety of different procedures can be safely performed in the outpatient setting,

the anesthetic approach can also vary widely. Monitored anesthesia care can be utilized as the

sole anesthetic technique for brief procedures, and the use of local and regional therapies can

mitigate the potential side effects of systemic anesthetics.

Regardless of the anesthetic route utilized, it is critical for providers to manage the

preoperative expectations of both the child and the parents, and to also provide adequate control

of postoperative pain and nausea and/or vomiting. Preoperative preparation can help both the

child and the parent acknowledge and address their fears, and set their expectations for the

operation and recovery. Such practices are routine among inpatient procedures in children’s

hospitals, but less common in the outpatient setting [19]. A recent study described the

development a web-based tool designed to guide families through this process for outpatient

operations, with the potential to improve the patient’s and the parents’ anxiety, as well as

establish a greater therapeutic relationship with the surgeon [19].

Postoperative symptoms, especially pain, can be difficult to manage even for children

undergoing inpatient surgery. Patients undergoing outpatient operations may be at an even

greater chance of inadequate postoperative analgesia, potentially resulting in repeat emergency

department visits or readmissions [16]. Consequently, providers have developed multiple

strategies to mitigate postoperative pain, most commonly utilizing multimodal therapy. Non-
pharmacologic therapies, such as breathing techniques for anxiety control, form a solid backbone

on which to incorporate medications [19]. In addition, some reports suggest that listening to

music in the postoperative period can decrease pain and anxiety in accordance with the gate

control theory of pain modulation [20].

Other strategies for postoperative analgesia begin preoperatively. One study

demonstrated that a combination of preoperative nebulized dexmedetomidine and ketamine

resulted in a smoother induction of analgesia, decreased Post Anesthesia Care Unit recovery

times and improved rates of discharge to home [21]. Other reports recommend perioperative

administration of acetaminophen to minimize pain and nausea/vomiting on emergence from

anesthesia [22, 23]. Irrespective of the combination of medications utilized, control of

postoperative symptoms is a crucial component of providing anesthesia for outpatient operations.

Single Visit Surgery

Some centers have streamlined the ambulatory surgery experience even further into “one-

stop” surgery, or single visit surgery (SVS). Such strategies were first described in the late

1990s, but much like outpatient surgery itself have yet to gain significant momentum among a

majority of centers. In this model of ambulatory surgery, the preoperative visit is performed on

the same day as the operation. Referrals from community physicians are reviewed by clinic

nurses to select specific diagnoses that are appropriate to SVS [15, 24]. The selection of specific

diagnoses is crucial to successful implementation: not only they should be appropriate for

surgical repair in the ambulatory setting, but they must also be easily recognizable by community

physicians to minimize incorrect diagnoses, and should not require prior insurance company
authorization. Patients are pre-screened via telephone by experienced clinic nurses, and

instructed about when to stop taking anything by mouth (NPO) for their appointment date.

The SVS day begins with four or five patients for the first hour of the morning who have

all been pre-screened by telephone by experienced nurses. Only patients with obvious inguinal or

umbilical hernias or other ambulatory diagnoses are brought in for this SVS clinic. Other

diagnoses include skin lesions such as dermal inclusion cysts, sebaceous cysts, skin tags or

uncomplicated pilonidal disease. Circumcisions over four months of age are also included;

under four months, these infants may be circumcised in the pediatric surgery office under local

anesthetic. Provided that the referred diagnosis is correct, the patient has remained NPO, and has

no anesthetic concerns, surgery is typically performed in the afternoon, with discharge home

from the recovery unit. Follow up typically occurs via telephone, with the option to return to

clinic for additional specific concerns [25].

SVS has a clear advantage over traditional models of ambulatory surgery, saving a great

deal of time for the families who do not need to take additional days out of their schedules to be

evaluated preoperatively in a clinic on a day other than the surgery day [15]. One study even

found that the total operating room time, including anesthesia, was decreased in SVS patients

undergoing umbilical hernia repairs or circumcisions [24]. Another program scheduled all their

SVS cases on Fridays, so as to minimize disruptions to the patients’ school week [13].

Scheduling patients for SVS however does require a degree of confidence in the correct

diagnosis. The combination of incorrect diagnoses, NPO violations, inappropriate patient

selection and the presence of respiratory symptoms can result in cancellation rates from 16- 20%

[15, 25]. Implementation of such a program therefore requires anticipation of such

satisfaction with the program.

Many factors make SVS especially efficient for the surgeon in addition to limiting the

types of procedures. The telephone review by experienced nurses helps with patient selection by

only including patients who are amenable to this setting: eager for surgery with convenient

access to the surgery center and also those who agree that surgery is needed after diagnosis by

their primary care physician. In addition, nurse review helps to avoid patients who may be

reluctant to have surgery, especially without discussion with the operating surgeon. Sometimes

the screening will detect other social issues such as limited transportation that make a particular

patient more likely to cancel or to require the expanded resources of the hospital. The

prescreening is very effective at converting office consultations to actual surgery cases. Review

of our individual institutional data shows that the rate of confirmation of the SVS patients ranges

from 80 – 90%, which is two to three times higher than the rate for our standard general surgery

clinic.

Practical Considerations in Establishing Ambulatory Surgical Practice

Ambulatory or outpatient surgery for common low risk pediatric surgical conditions has

clear benefits for all parties involved and has therefore been widely adopted. Designing an

ambulatory surgery program, however, requires careful attention to all the aforementioned

details regarding patient and procedure selection. Compliment et al described their experiences

in establishing an ambulatory surgery center solely for tympanostomy tube insertion [9]. They

convened a multidisciplinary team consisting of surgeons, nursing staff (including specific

representatives for the recovery and operating rooms), anesthesiologists, and various
administrators to repurpose a partially unused area of their facility into an outpatient surgery

suite. In doing so, they increased their number of tympanostomy tube insertions and decreased

direct and indirect operating room costs while generating additional net revenue from the

ambulatory suite [9].

Another consideration in establishing ambulatory practice patterns regards postoperative

follow up. Traditionally, postoperative patients are evaluated by the surgeon in the clinic but, for

many patients, the postoperative visit is unnecessary because any problems or complications

usually become obvious prior to that visit and are dealt with as needed. In addition, families do

not wish to return for a visit that often includes waiting and lost time from work or other

activities [26, 27]. The postoperative visit can be associated with significant costs, primarily for

lower income patients [5]. As such, telephone follow up has emerged as a viable alternative,

which allows for the majority of postoperative questions and concerns to be addressed at

decreased cost and time to the clinic staff and improved convenience to patients and their

families. Studies have generally reported improved satisfaction with phone follow up among

both families and clinic staff [26, 27].

The efficiency of the ambulatory care setting is due in part to patient selection but also to

the much lower cost of the outpatient surgery center compared to the general hospital setting.

Freestanding surgery centers have much lower overhead than hospitals [9]. If the centers are able

to obtain reimbursements similar to the main hospital then the savings are considerable. These

efficiencies are further augmented by development of specific guidelines, routines and

procedures tailored to the outpatient practice.

Conclusion
 Ambulatory surgery offers similar surgical outcomes compared to hospitalization for

pediatric patients undergoing common, low-risk procedures, and extends benefits to both

providers and healthcare systems including improved patient satisfaction, reduced complications

and more efficient care. The efficiencies are experienced both in the increased numbers of

patients that can be treated with similar costs and the decreased time commitment for both

families and providers. Within the scope of outpatient surgery practice, new trends continue to

emerge, changing the scope of practice from its inception out of necessity over a hundred years

ago. As perioperative care as a whole continues to evolve and improve, increasing numbers of

procedures may become eligible for ambulatory surgery, transitioning more children to

outpatient recovery and minimizing morbidity for both patients and their families.

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