Delivering Quality and Value

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Delivering Quality and Value

• Laparoscopic Cholecystectomy
• The Airedale Experience

Raj Kapadia John Scriven Sherie Herpe
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Background

• First 7th July 1990
• Over 50 procedures by end 1990
• Operating time 165mins to 50mins

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Background

• Advantages of Laparoscopic Surgery
• Decreased postoperative pain
• Early return of bowel function
• Shorter hospitalisation
• Decreased disability
• Better cosmesis

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Pathway DevelopmentDay Surgery

• Multidisciplinary Team
• Outpatient Staff
• Pre-operative Assessment
• Day Ward
• Anaesthetic
• Theatre
• General Practice

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The Airedale WayOutpatient Visit

• Clinical History and Examination Biliary colic
  or cholecystitis Previous abdominal
  surgery Masses, aneurysm
• Investigations Ultrasound MRCP, ERCP

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The Airedale WayOutpatient Visit

• Patients Journey Operation
• Complications BleedingInfectionViscus
  perforationBile duct injury Conversion

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The Airedale WayOutpatient Visit

• Verbal Consent
• Waiting Lists
• Written Information

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The Airedale WayPre-operative Assessment

• Assessment of co-morbidity
• Assessment of social problems
• Reinforcement of day care principles
• Written Information

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The Airedale WayDay of Surgery

• Admission
• Written Consent
• Pre-MedParacetamol 1 gmOmeprazole 20
  mgTramadol 50 mgMetoclopramide 10 mg

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The Airedale WayAnaesthetic Room

• Pre-Oxygenate
• IV Induction
• Fentanyl 100 mcg
• Midazolam 2 mg1
• Ondansetron 4 mg1
• Dexamethasone 4 mg1
• Propofol 2-2.5 mg/kg
• Rocuronium 0.4 mg/kg

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The Airedale WayAnaesthetic Room

• Patient not bagged
• Pro-Seal Laryngeal Mask
• Ventilate with Oxygen/ Air / Isoflurane
• Pressure Control ventilation at low pressure(15
  cm water)
• Rates of 12 -16 /min

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The Airedale WayOperating Room

• Theatre table for head-up and lateral tilt
• Modern Camera System
• Good Working Instruments

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Modern Stack
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The Airedale WayOperating Room

• Infiltration of port sites
• Low pressure pneumoperitoneum
• Minimal trauma around operating site
• Thorough Lavage with saline
• NO on-table cholangiography

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The Airedale WayOperating Room

• A Good Cohesive Team
• Anaesthetist
• Anaesthetic Assistant
• Scrub Nurse
• Camera Operator
• Surgeon

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The Airedale WayRecovery Room

• IVI stopped
• Morphine incrementally up to 10mg
• Oral fluids

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The Airedale WayDay Ward

• Monitor vital parameters
• Analgesia
• Oral fluids and solids
• Nurse-led discharge

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The Airedale WayDischarge

• Discharge when stable
• Criteria- based
• No time constraint
• Post-op Analgesia Paracetamol 1 gm
  qds Tramadol 50 mg qds Ibuprofen
  400 mg qds

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The Airedale WayAfter Care

• No Follow Up

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Pathway Development

• Evolution
• Continuous learning
• Introduction
• Consolidation

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The Airedale WayFuture Refinements

• Increase day case rate
• Improve analgesia
• Decrease conversions
• Increase penetration Diabetics Obese Emergency
• Patient Safety First

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