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Ambulatory surgery in elderly patients continues to increase - avoiding hospitalization and thus postoperative cognitive dysfunction in older patients being its major objectives. An upper age limit in outpatient anesthesia does not exist to date. However, functional rather than chronological age is crucial in patient selection. In consensus discussion, baseline functional status should be evaluated regularly - defined as everyday behaviors necessary to maintain daily life and encompassing areas of physical, cognitive, and social functioning. Moreover, frailty in elderly patients can be quantified objectively and is associated with increased perioperative morbidity in ambulatory general surgery. The decision for or against outpatient anesthesia therefore remains a case-by-case decision which should be discussed within a team., Competing Interests: Die Autoren erklären, das keine Interessenkonflikte vorliegen., (Georg Thieme Verlag KG Stuttgart · New York.)

The number of operations carried out on an outpatient basis is increasing in Germany. This trend has been observed for years. The prerequisite is an infrastructure that is in line with guidelines. The competence of the anesthetist must not be restricted to that of a standard specialist anesthetist, but the physician should have experience in ambulatory anesthesia. Well-adjusted comorbidities of the patient are generally not a contraindication for an outpatient procedure. The heavily overweight patient can also be operated on an outpatient basis if he is compliant, comorbidities are well adjusted and intensive postoperative care is ensured. Obstructive sleep apnea syndrome is per se not a contraindication for carrying out a surgical intervention on an outpatient basis. The intensive postoperative care and the presence of a CPAP device are also important in the recovery room. An important decision criterion in cardiac patients is the determination of the metabolic equivalent (MET). A MET value > 4 is considered sufficient for outpatient procedures. Postoperatively, the patient can be discharged home when the surgeon and the anesthetist are convinced that the condition of the patient is stable. A sensible companion and instruction to the patient that he is not allowed to actively participate in road traffic are essential for discharge after surgery. The decision on outpatient or inpatient care must always be taken individually. It is not possible to make a general statement as to the manner in which an intervention should be carried., Competing Interests: Interessenkonflikt: Die Autoren erklären, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Although regional anesthesia for ambulatory patients is feasible, effective and recommended, general anesthesia, analgosedation and monitored anesthesia care traditionally play a major role in the ambulatory setting. This discrepancy is at least partially caused by a more standardized and predictable process when using general anesthesia. High patient comfort, a low rate of complications and a rapid postoperative recovery are expected by all patients, irrespective of the type of anesthesia chosen and lie in the common interest of the anesthesiologist and the surgeon. A careful selection of suitable regional anesthesia procedures for equally suitable patients achieves these goals without loss of efficiency., Competing Interests: Interessenkonflikt: Dr. Andreas Krier hat in der Vergangenheit Beraterhonorare von Sintetica GmbH erhalten., (Georg Thieme Verlag KG Stuttgart · New York.)

Legislation, regulations and rules must be complied with when conducting ambulant surgeries and administering ambulant anesthesia. Additionally, there are social welfare legislation and regulations, as well as technical guidelines and standards that must be complied with, for instance, regarding the management of medical products or the disposal of waste and sewage in medical practices. At a country level, many of these regulatory areas are managed differently by each German state, and in some instances management differs significantly from one state to another. Social and employment legislation, as well as regulations for ambulant operating physicians and business operators have to be observed. In order to prevent nosocomial infections, there is a focus on maintaining compliance with hygiene regulations and the Infection Protection Act. There are a variety of possible operational models and ways to organize ambulant operating rooms. The particular model that is best for a specific practice will depend on the local circumstances. That being said, particular attention should be given to patient-centered, stress free surgical patient care, which should be prioritized over the business. Ambulant surgery can be performed in private practices, as well as hospitals, and the two usually differ significantly from one another. On the one hand there are the well-organized, high performing, private practices, which have a focus on ambulant surgeries, where the participating physicians contribute to the success of the practice. On the other hand, there are the often large and cumbersomely organized hospitals, where ambulant surgeries are viewed as more of a burden than as an additional source of income., Competing Interests: Interessenkonflikt: Die Autoren erklären, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: TAPP surgery can be considered as a gold standard in inguinal hernia repair. Patients benefit of a faster reconvalescence and less pain compared to other techniques. TAPP surgery in Germany is performed in an in-patient setting routinely. However, according to European guidelines, inguinal hernia surgery should be considered as day-case surgery whenever possible., Objectives: The safety of day-case surgery was examined in relation to postoperative pain, complications, comorbidities, recurrent inguinal hernia and bilateral procedures., Material and Methods: In a retrospective, monocentric study we analyzed 522 elective inguinal hernia repairs using TAPP technique in a specialized hernia center. Supplemental data from Herniamed registry is analyzed., Results: Parts of the procedures should be performed in an in-patient setting, whereas a much larger number of cases should be carried out as day-case surgeries. Logistic regression analyses show that "age", "bilateral procedures" and "comorbidities" affect the complication rate. "Age" and "recurrent inguinal hernia" are risk factors for an increased need for analgetic medication. Furthermore, we present an actual distribution of day-case vs. in-patient surgeries in inguinal hernia repair based on data from the Herniamed registry., Conclusion: A much larger part of procedures could safely be carried out as day-case surgeries. Based on a false incentive there is an incorrect steering in the German health system. These procedures cannot be carried out covering the costs as day-surgery cases. If there is no reevaluation of the proceeds of these procedures in a day-case surgery setting, the reasonable quality in treatment is compromised especially in inguinal hernia surgery.

The basis of surgery of great saphenous vein insufficiency is the concept of "privat circulation" coined by Trendelenburg in 1891. It was only logical that the dissection of the insuffcient vein or it's partial or complete resection could bring about healing. Over the years varicose vein stripping was modified to finally result in the highly effectiv concept of crossectomy and stripping. For decades this was the Goldstandard in surgery of varicose vein insufficiency. All the other minimally invasive therapeutic techniques which have been developed in the last decades had to compete with crossectomy and stripping. Thanks to progress in technical development the classic stripping procedure has been replaced by highly effectiv, minimally invasiv procedures, at least in the western industrialisied countries. For a minority of patients with specific anatomical pathologies as well as countries with limited health resources vein stripping remains a surgical standard procedure.

A compromised overview of surgical techniques regarding the nose (functional) and para nasal sinus inflammation surgical treatment is exposed in this article. The nasal septum is within the focus for function, form and stability for the nasal structure (especially for tip and back of the nose) and for success of a rhinoplasty. An important role play the lower nasal turbinates regulating nasal air flow and thus having a great effect after turbinate surgery (submucosal resection and lateral fracturing).The endonasal endoscopy is of utmost importance for diagnosis, therapy and detection of recurrence. In severe cases of nasal polyps, functional endoscopic sinus surgery (FESS) remains the ultimate therapy. However, the indication to operate will be carried out after exhaustion of medical treatment. The most important recurrent prophylaxis for rhino sinusitis and nasal polyps is an appropriate post operative nasal care., (© Georg Thieme Verlag KG Stuttgart · New York.)

Due to modern surgical and anesthesia techniques, many patients undergoing small or even medium surgical procedures will recover within minutes and can then be discharged after a few hours of monitoring. Aside from an optimized surgical technique, a precise and differentiated anesthesia concept is needed to guarantee rapid recovery and home readiness. Nowadays, remifentanil-propofol represents the standard regime in ambulatory anesthesia. The use of alfentanil, desfluran or sevofluran is also possible whereas other intravenous or inhaled anesthetics or other opioids are rarely used. If endotracheal intubation is necessary, a reduced intubating dose of neuromuscular blockers (NMB), such as mivacurium, atracurium and rocuronium, i.e. 1-1.5-times the 95 % effective dose (ED95) is a good possibility to accelerate neuromuscular recovery while still having acceptable intubation conditions. Due to its limitations and contraindications, succinylcholine is not the first choice but may be used in non-fasting patients in need of urgent (ambulatory) surgery, e.g. in bleeding women undergoing dilation and curettage. Even with these reduced dosages monitoring of neuromuscular recovery is crucial and should be applied to all patients when NMBs are used. Furthermore, patients should receive a risk-adapted postoperative nausea and vomiting (PONV) prophylaxis, e.g. with 4 mg dexamethasone and 4 mg ondansetron. Postdischarge nausea and vomiting (PDNV) should be anticipated by a new risk score and prophylaxis or treatment should be initiated. For postoperative pain relief, local or regional anesthesia techniques, such as infiltration, field or nerve blocks should be applied where possible. In addition, non-opioid analgesics are the basic treatment while longer-lasting opioids are only necessary for some patients.

Outpatient anaesthesia has increased considerably in recent years. More complex procedures are performed on an outpatient basis and patients suffer from more co-morbidities. A patient- and procedure-centred risk management system includes guidelines for patient-selection and -evaluation, selection of adequate anaesthetic drugs, structured post-anaesthesia care and discharge-procedures, and a critical incident management plan. Risk management for ambulatory anaesthesia is supposed to reduce malpractice and prevent complications. Ultimately, procedure related cost will decrease and confidence as well as satisfaction of patients, surgeons and anaesthesia team members will increase., (© Georg Thieme Verlag Stuttgart · New York.)

Outpatient anesthesia care for children undergoing smaller surgery may offer advantages when the conditions are optimized. The overall competence of the institution in addition to the qualifications of the anesthesiologist is crucial for a high quality result. This includes standardized approaches for perioperative management (premedication, pain therapy, PONV prophylaxis, postoperative monitoring etc.), facilities with age adjusted equipment, medical staff with experience in the care of children, regular training of emergency situations in the team and clear concepts for the postoperative care., (© Georg Thieme Verlag Stuttgart · New York.)

Background: In Germany there is currently no national standard for the management of patients with obstructive sleep apnea syndrome (OSAS). The object of this survey was to obtain information on the treatment concept for patients with OSAS and to report on the current practice in Germany., Methods: Data collection was obtained through an online questionnaire. A total of 12,113 members of the supporting anesthesia societies from all over Germany were invited to participate via e-mail. Additionally an announcement was made in a professional journal., Results: A total of 1,671 questionnaires were analyzed. The average age of the respondents was 45 years, 64% were male and 36% were female. The average work experience was 16 years and 85% of the respondents were consultants. In total 85% of anesthesiologists were predominantly working in inpatient care and 12% were predominantly active in outpatient care. Of the respondents 63% preferred regional anesthesia, 20% preferred general anesthesia for patients with OSAS and 17% did not have a preference for a specific anesthesia procedure. Outpatient surgery for patients with OSAS was performed by 72% of the respondents using regional anesthesia and by 55% of the respondents using local anesthesia with sedation. Of the anesthesiologists 49% consented to outpatient surgery using general anesthesia and 14% to interventions involving the airways. Compared to anesthesiologists working predominantly in inpatient departments, those working predominantly in outpatient departments treated patients with OSAS more frequently on an outpatient basis, used general anesthesia significantly more often, discharged those patients significantly earlier and observed less complications., Conclusions: This survey shows that outpatient surgery for patients with sleep apnea is common practice in Germany. It is also performed when patients have moderate or severe OSAS and for respiratory tract surgery. This means that the management is not conform to the guidelines of the American Society of Anesthesiologists (ASA).

Background: In many European countries, patients requiring surgical treatment of ankle fractures are generally hospitalized for an average of 8-11 days. This anecdotal concept is largely based on the premise that the inpatient monitoring of soft tissue conditions may lead to a decreased complication rate. The present study was designed to test the hypothesis that the surgical care of isolated ankle fractures as an outpatient procedure represents a safe and feasible concept which is not associated with an increased complication rate., Methods: A retrospective analysis was performed of a prospective database during a 5-year period (01/01/2005-12/31/2009) at a US academic level 1 trauma center with an institutional protocol of outpatient surgery for isolated ankle fractures. All fractures were classified according to the AO/OTA system. Outcome parameters consisted of the rate of postoperative complications and frequency of unplanned surgical revisions outpatient isolated versus inpatient isolated with surgical fixation of ankle isolated fractures., Results: Among 810 consecutive patients with ankle fractures during the study period, 476 met the inclusion criteria. Of these, 256 patients (53.8%) were treated as outpatients. The average length of stay of patients who were admitted as inpatients was 1.5±0.8 days (range 1-5 days). The age distribution was in a similar range for inpatients and outpatients (39±14.1 vs 35±12.8 years), and the injury severity based on the AO/OTA fracture classification revealed a similar distribution of fracture patterns in both groups. The rate of postoperative complications (9.1 vs 3.1%) and of unplanned surgical revisions (3.6 vs 1.2%) was significantly increased in the hospitalized group, compared to patients with ambulatory surgery (P<0.05)., Conclusion: The surgical treatment of isolated ankle fractures as an outpatient procedure represents a safe and resource-efficient concept which is not associated with an increased complication rate. Cultural differences in the domestic environment of individual patients may have to be taken into consideration.

Aim: A rarely described Achilles tendon lesion resulting from Haglund's disease and its repair is presented., Method: An analysis of the respective clinical records was carried out., Results: Haglund's resection was performed from a 3 cm lateral transverse approach. A coincidental anterior Achilles tendon partial tear was repaired by transversal U-sutures., Conclusion: A minimally invasive repair of a partial tear of the anterior Achilles tendon is feasible and effective., (Copyright (c) Georg Thieme Verlag KG Stuttgart-New York.)

Background and Objective: Since the beginning of 2001, Doppler-giuded ligation of the hemorrhoidal arteries (DG-HAL) has been used at this clinic in almost all patients with various forms of hemorrhoidal disease. Aim of this study was to ascertain whether this intervention can be done without general anaesthesia, the hemorrhoidal knots regress and this procedure provides advantages over the classical methods of treating hemorrhoids., Patients and Methods: Early results of DG-HAL in 248 patients are presented. Through a special proctoscope the arteries leading to the hemorrhoidal cushions are located in the pain-free rectum under Doppler guidance and suture ligated. The form of anaesthesia, duration of the operation, numbers and sites of the ligatures, additional interventions and postoperative complications were recorded., Results: 171 patients (69%) needed no anaethesia. 147 patients (Without additional interventions) were re-examined 6 weeks after the operation: 61.2% were free of symptoms. A total of 87.7% were at least improves. The complication rate was low., Conclusion: In our experience DG-HAL has been a well tolerated efficacious method with few complications in the ambulatory treatment of hemorrhoids. The ideal indication for this methods is nonprolapsing hemorrhoids.

In a 69-year old patient, with a symptomatic ICA stenosis a stent implantation was performed under outpatient conditions. An interdisciplinary consensus was reached that the patient was suitable for outpatient therapy. In accordance with the NASCET criteria, the patient was to be classified to the high-risk group. Within 120 days before the intervention, the following clinical symptoms had occurred: 1 TIA, 2 amaurosis fugax. In the diagnostic angiography a right postbulbar ICA stenosis of 97% was verified. The stent application and subsequent PTA were performed under protection using a filter system. The transfemoral route was always fitted with an endovascular closure system. The neck vessels were followed-up by means of colour coded duplex sonography (CCDS) on days 1, 30, 180 and 360. A contrast-medium intensified MRI was performed on the 5th day post-intervention. The implantation of the stent and PTA were done without any complications. Atheromatous plaque fragments were found in the protection system. A plaque embolism was excluded clinically and in the contrast-medium intensified MRI 5 days after the intervention. After 360 days, no restenosis was found in the CCDS, the ECA was perfused. The method presented is low in complications and shows a high success rate. If patient recruitment is adequate, this intervention can be performed on an outpatient basis.

Expansion of ambulatory surgical care is a major focus in United States health politics. In 1996 a total of 31.5 million ambulatory operations were performed, currently accounting for 45% of yearly procedures. Operations in ophthalmology and gastroenterology are predominant. Ambulatory surgery is organized in different forms: "office-based surgery," "hospital outpatient departments," and "ambulatory surgery centers" (ASC). The numbers of ASCs are rapidly increasing. The current proportion of ASCs is 16% of all operations. The type of ambulatory surgery is primarily defined by payors. Medicare standards are the benchmark for private organizations. Recovery care centers now offer postoperative care beyond the former 23-h threshold. This may lead to a further expanded ASC access. Revenues for ambulatory surgery were so far mostly based on fees for service. The implementation of an outpatient prospective payment system ("OPPS") is planned by Medicare, using fixed package prices within a newly defined ambulatory payment classification ("APC"). The dimension of structural changes could be enormous and possibly be compared with the implementation of DRGs in 1983.

Background: Using small endoscopes it is now possible to evaluate the status of lacrimal ducts in vivo. GRIN-Lenses produce better pictures from the lacrimal ways than fiber-bundles. GRIN-endoscopes are rigid. The present study is concerned with the feasibility and indications of such GRIN-endoscopic examination., Patients and Methods: Two different GRIN-endoscopes with a distal diameter of 0.89 mm were used. One with a phi 0.5 mm optic and an additional working channel and another one with a phi 0.35 mm optic and two additional working channels. One channel each was used for injection of air or 0.9% NaCl. Either a laser fiber or another instrument (max phi 0.16 mm) could be introduced into the second channel. 44 patients in age between 18 and 87 with symptoms of epiphora or signs of chronic lacrimal way affections were examined., Results: The presaccal lacrimal ducts could be clearly visualized in all patients. In case of presaccal stenosis, the examination of the lacrimal sac was not always possible. The endoscope used, based of GRIN-lenses, gave an excellent image quality. Endoscopy under local anesthesia was well tolerated by all the patients with affection of the lacrimal drainage system. Because this ambulant examination does not stress the patient too much, it could be repeated a number of times. Endoscopy under general narcosis could enlarge the application spectrum. This method can complement the ambulant diagnostics and therapy of the lacrimal drainage system.

Prerequisites for outpatient surgery performed by primary care physicians are fundamental anatomic knowledge and basic surgical skill. A precise clinical and functional examination of the affected area must precede every wound care, treatment of infection or excision of a skin lesion. The surgical procedure and postoperative care must be determined and discussed with the patient. Lesions with defect and lesions of neurovascular structures as well as deep infections of the hand, stab and bite wounds must be taken care of by a specialist. Histologic examination of excised skin lesions is mandatory. Malignant melanomas have to be considered by a interdisciplinary treatment regimen.

The majority of surgical interventions about the hand can be done on an outpatient basis and in private practice; however, the surgeon must be well-trained in hand surgery and should master all forms of local and regional anesthesia, permitting an atraumatic technique. In addition, he must be prepared to handle any peri- and intraoperative complication and should be able to refer the patient to a close-by hospital in case of need. Since the aftercare appears to be of paramount importance for a successful outcome, the postoperative rehabilitation must be guaranteed as well. As all these conditions require qualified manpower and a good infrastructure, hand surgery is probably best performed within a small group of practising surgeons.

From 1988 to 1989, we operated on 784 women in our daily ambulant clinic. In 462 of these cases, we performed laparoscopic surgery with 679 therapeutical interventions. Sterilisation is the most frequent operation in our cases of Fallopian tube surgery, but we have also had tubal pregnancy in 5 cases. In ovarian surgery, we found a great number of benign ovarian cysts followed by a high rate of ovarian adhesions, which, counted together with the Fallopian tube and intestinal adhesions, amounted to 201 cases. In 9 women, the extirpation of a myoma was necessary and the largest one was 5.5 cm in diameter. In comparison with the total number of our surgical interventions, we had a high rate of appendectomies. Each surgeon is aware of the various locations of the appendix, of its close relation to the adnexae and the difficulty of clinical diagnosis of appendicitis in women, especially in pregnant women. We removed the appendix in two pregnant women (4th and 18th week of pregnancy). A pathological substrate was found in more than 80%. Because of a good preliminary selection of our patients, we found no carcinoma in the abdominal cavity, except from an early metastasis on the appendix of an ovarian carcinoma. This patient came for staging re-laparoscopy after treatment of the ovarian carcinoma years ago. Since the beginning of 1989, we have used a Neodym: Yag laser in endoscopic operations. The good cutting effect loses its benefits of precision and time saving through bleeding as soon as a large vessel is involved.(ABSTRACT TRUNCATED AT 250 WORDS)

The introduction of the stab-incision--phlebectomy (Muller's technique)--has opened a large field for ambulatory surgery. This is specially true when phlebectomy is combined with a saphena-femoral or saphena-popliteal ligature. In a series of 1825 operations including 1592 incompetent saphenous veins 1216 (67%) were performed under local anesthesia. Radical surgery of incompetent short saphenous veins as well as of minor forms of varicose long saphenous veins is feasible in local anesthesia. Regional or general anesthesia (609 operations) are still recommended for stripping procedures in advanced long saphenous varices. In most cases phlebectomy of varices (553) provides a better cosmetic result than sclerotherapy, the latter being the treatment of choice for small veins and telangiectasias. Ambulatory surgery and sclerotherapy are cost-effective and low-risk treatments. No deep vent thrombosis or pulmonary embolism was observed in this group, whereas 1 DVT and 2 PE occurred in the 609 operations performed under general anesthesia.

The spectrum of plastic surgery is wide. It covers constructive, reconstructive and anaplastic surgery. A considerable portion of the operations can be carried out ambulatorily. Several examples show the practicability and limits. They are different according to the orientation of the surgeon and the equipment in his practice. Unfortunately also economic problems must be pointed out.

Based on experience with 3100 tubal sterilizations and other pelviscopic operations the following conclusions are drawn: 1. Most endoscopic gynecologic operations can be performed as outpatient procedures by experienced gynecological surgeons without increased risk for patients. But not in all cases these operations can be done on an outpatient level a priori as by many american health insurance companies expected. 2. Most short operations don't need to be performed in general anaesthesia. Risks and costs can be reduced using local analgesia or "volonelgesie". 3. Such short operations can mostly be done with a single puncture laparoscope, more punctures for additional instruments should only be made if it is necessary. 4. Patients with chronic pelvic pain are able to give support in searching and finding painful organs under "volonelgesia". The treatment of these organs can be performed by injection of a local anaesthetic or in general anaesthesia. That necessitates cooperation between gynecologists, anaesthesiologists, nurses and patients which should be part of educational and training programs.

The necessary prerequisites for quality assurance are described. An analysis of the frequency and the scope of outpatient operation in the 91 surgical practices in Northern Württemberg, FRG, shows that, for the average practice, its significance is rather low. In contrast to this, the statistics of 41 practices of the "working group of outpatient operation of the BDC" show a clearly higher and more sophisticated capability, due to an annual operation frequency of 683 to 3008 operations. Reference is made to the importance of the out-patient operation for health politics.

Pediatric surgical operations performed on an ambulatory basis in a practice are still rare in Germany. Prerequisites, indications, possibilities and limitations are presented. Some 869 operations were performed under general anesthesia within 21 months. Of the children 70% were under 5 years of age. The postoperative results were evaluated by means of a questionnaire in 352 children. Early complications occurred in five instances (1.4%) and late complications in one child (0.3%); hernia recurrence). Observing the possibilities and limitations, ambulatory pediatric surgery yields good results and takes the peculiarities of children into consideration.

This study is based on 632 outpatient and 1948 inpatient repairs of inguinal hernias. Outpatient organisation, surgical technique, anaesthesia and after-care are described in detail. Complications, such as disturbed wound healing and recurrences also the time being out of work are dealt with. These data are compared with those patients who underwent the inguinal hernia operation as an in-hospital procedure. The authors postulate that outpatient surgery of inguinal hernia has many advantages over the inpatient operation.