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Background: Most surgical procedures in Norway are performed on an ambulatory basis. Many types of health professionals are involved and need training in how to handle these patients. The paper reviews important aspects of handling ambulatory surgical patients., Material and Methods: The authors' research, clinical experience from ambulatory anaesthesiology and literature identified through a non-systematic search in Medline and EMBASE form the basis for the article., Results: With the advent of modern techniques, anaesthesia is no longer a limiting factor for whether surgery can be performed on an ambulatory basis or not. The decision to hospitalize a patient after elective surgery is based on limitations in the patient's general health, daily functioning and psychosocial status or the type of surgical procedure planned. When assessing whether surgery can be elective or not it is valuable to consider the entire treatment chain and ask the following questions: Can this patient who has undergone this procedure be expected to cope with transport and staying at home or in a hotel the same day as the operation, when escorted by an adult until the next day? - and is it safe?, Interpretation: To ensure good planning and performance, it is important that the anaesthetist has access to up-to-date information on planned surgical procedures, the patient's general health, use of medication, allergies and level of daily functioning.

Background: Frozen shoulder is a debilitating, long-lasting condition. At Bergen Surgical Hospital we have performed arthroscopic capsular release since 2003 in patients where conservative treatment has failed. The procedure is done as day surgery. The purpose of this study was to evaluate our results., Patients and Methods: From June 2003 until October 2005 arthroscopic capsular and ligament release was performed in 66 patients (70 shoulders) with primary frozen shoulder. Oxford shoulder score and range of motion were recorded prospectively. Follow-up was done during autumn 2005 and included subjective evaluation of symptoms, function, satisfaction with the result of the procedure, Oxford shoulder score and clinical examination., Results: 62 out of 66 patients would agree to have the same procedure done again. Degree of satisfaction with the result of the procedure (0 = worst, 10 = best) was 8.6 +/- 1.8 (SD) on average. Ability to work, physical activity and quality of night's sleep improved significantly (p < 0.001). Oxford shoulder score (12 = best, 60 = worst) decreased significantly from 41.0 +/- 7.5 (SD) to 18.4 +/- 7.3 (SD) (p < 0.001). External rotation, abduction and flexion increased significantly (p < 0.001)., Interpretation: The results from treatment of frozen shoulder with arthroscopic capsular release are good and suggest that the the condition shoulder is shortened. The procedure may be done safely as day surgery. We feel that more patients may benefit from the procedure.

Background: The purpose of this study was to investigate cholecystectomy incidence and laparoscopy rates in Norway (1990-2002)., Methods: Data were compiled from the Norwegian Patient Registry based on codes for cholecystectomy., Results: From 1990 to 2000-02, age-adjusted incidence rate (per 10,000 inhabitants) for cholecystectomy increased from 2.9 to 4.1 for men and from 7.0 to 11.8 for women. Incidence rates varied between counties. The proportion undergoing laparoscopic surgery increased from 1% in 1990 to 89% in 2000-02. Over the same period the length of postoperative inpatient stay decreased from 7.3 days to 3.3 days. 94% of electively admitted patients were operated by laparoscopic technique in 2000-02. Among patients admitted on an emergency basis, women below 50 were more often operated by laparoscopic technique than older women and men., Conclusion: Substantial changes in the treatment of gallstone disease occurred in Norway over the period 1990 -2002. Increased incidence rates for cholecystectomy and reduced length of postoperative inpatient stay were observed after the introduction of cholecystectomy by laparoscopic technique.

Background: Increased awareness of post-hernia repair pain motivated a study of pain and rehabilitation after day surgery., Material and Methods: Forty male patients were prospectively randomized to conventional (McVay) or open mesh repair. Self-assessment of postoperative pain was based on a four-step verbal scale. Patients and the physicians conducting the study were blinded to the surgical method. Clinical follow-up was performed twice, after four weeks and median 21 months., Results: The open mesh technique generated less pain during the first postoperative week. Chronic light to moderate pain occurred in 20% of patients irrespective of surgical method. A sick leave of one to three weeks was sufficient in 20 out of 27 patients., Interpretation: The study showed no clinical advantage of a tension-free method in terms of rehabilitation and post-hernia repair after the first postoperative week. Because of the relatively high incidence of late treatment-related pain, non-symptomatic adult patients should not be referred for inguinal hernia surgery. The primary sick leave period should not exceed three weeks.

Gallbladder stones are common, but most persons with stones are asymptomatic. The symptoms of gallbladder stones are usually characteristic. They are often associated with other types of abdominal symptoms, which are not affected by cholecystectomy. Day surgery laparoscopic cholecystectomy is increasingly popular. The operation may be associated with serious complications, but the risk is low. 85-90% of patients operated with cholecystectomy are asymptomatic after the operation.

Background: Day-case laparoscopic fundoplication for gastro-oesophageal reflux disease was introduced in January 1997., Material and Methods: Inclusion criteria were ASA grade 1-2, living within 30 minutes by car from the hospital, or staying over in the patient hotel the first night, with company. Initially, only selected patients were offered day-case treatment; later it was adopted as routine. The patients underwent general intravenous anaesthesia with propofol and remifentanil and were given prophylaxis against postoperative pain and nausea. The surgical procedure was Nissen-Rossetti fundoplication or semifundoplication., Results: 83 patients were included. Ten patients were admitted, 73 (88%) were discharged as planned 3-8 hours after the operation. Eight patients (10%) were readmitted; one of them underwent reoperation for necrosis of the gastric fundus. Eight patients visited the outpatient department without need for readmission. At seven-day follow-up, 55 discharged patients (75%) were satisfied with the day-case treatment, nine (12%) were indifferent, and nine (12%) were dissatisfied, mostly because of pain. If offered a similar operation in the future, 50 patients (68%) would have preferred and 11 (15%) would have accepted day-case treatment; 12 (16%) would not., Interpretation: Outpatient laparoscopic fundoplication is safe and well tolerated by the majority of patients.

Introduction: Reduced economic resources have been a stimulus for increased day-case surgery, and an incentive for improving surgical technique and anaesthetic methods. In hernia surgery it is important to avoid recurrence and reoperation, which seems to be more easily achieved by the use of mesh prosthetics. For anaesthesia, costs may possibly be reduced by the use of spinal blockade instead of general anaesthesia, but also local infiltration anaesthesia is regaining popularity. We found it appropriate to evaluate and compare relevant factors associated with the use of these two anaesthetic techniques in our day-case surgery., Material and Methods: Evaluation and analysis of the anaesthetic and postoperative notes on 413 adult patients with inguinal hernia operated in local anaesthesia and 121 patients operated in spinal anaesthesia., Results: Cardiovascular, respiratory and neurological problems were more frequent and more severe in the spinal than in the local anaesthesia group, whereas the need for extra analgesia and sedation perioperatively was higher in the local group. Time spent in the operating room was shorter, and early ambulation appeared to lead to less discomfort in the local anaesthesia group., Interpretation: The results indicate that local infiltration is a safe, simple and effective technique when used for operations of abdominal hernias in adult patients, and can be recommended for day-case surgery of reducible inguinal hernias.

Background: The issues of whether minor surgery should be performed in private or public clinics and/or be funded by the national health service are under continuous debate in Norway., Material and Methods: A prospective study of the benefit of (adeno)tonsillectomies in 120 children is presented. Surgery included in the study was performed on an inpatient as well as an outpatient basis and in public as well as private clinics., Results: There was no difference in patient satisfaction or in the quality of surgery depending on the type of organisation. Relief of symptoms associated with (adeno)tonsillar infections and obstruction following surgery was consistent. Less euresis was found in the study population following surgery. Increased haemoglobin concentration and less protoporfyrin IX in erythrocytes indicate an improved erythropoiesis following (adeno)tonsillectomy. Less manpower was needed to perform (adeno)tonsillectomies in private compared to public clinics., Interpretation: We suggest that the Norwegian national health system opens up for funding surgery of established quality irrespective of whether it is performed in a public or a private clinic.

Inguinal hernia repair is associated with a variety of complications of which the recurrence rate is one of the most important. The aim of this study was to examine all patients one year after surgery for inguinal hernia in an outpatient clinic. 12 months after the operation patients were interviewed and physically examined. 172 hernias in 166 patients were repaired in 1996 in our outpatient unit. 17 surgeons used nine different techniques. Follow-up was achieved in 93.9% of patients alive. Ten recurrences were found (6.3%). Four of the patients were not aware of their recurrence. 11% of the patients still had discomfort or pain after twelve months, whereas 5.2% had not resumed full activity. Other complications occurred in more than 20% of the operations. A "free to do policy" in inguinal hernia repair results in high recurrence and complication rates even in the hands of experienced surgeons in our clinic. The present study shows that an interview as well as a physical examination are necessary in evaluating recurrences, postoperative complications, postoperative pain and time to full mobilisation. Without physical examination, the recurrence rate would have been underreported.

Ear, Nose and Throat (ENT) procedures are the most common types of surgery in children and include adenoidectomy, tonsillectomy, myringotomy, ventilation tube insertion or combinations of these. In order to study disease profile and routines for referral and treatment in outpatient otolaryngologic surgery, data were collected from 178 children operated consecutively during a six-week period in 1998. Median time from referral to surgery was less than four months. The majority of children operated for recurrent acute otitis media, tonsillitis or upper respiratory infections had suffered from the disease for 12 months or less. Obstructive symptoms were registered in 18% of these children. Most patients were referred to the hospital by specialists in otolaryngology or paediatric medicine. Surgery was more common in male than female-children, and median age at the time of surgery was 4.2 years. There was an equal distribution of middle ear and pharyngeal surgery.

Most current studies show that adenotonsillectomies can be performed safely as day case surgery. We wanted to evaluate patient acceptability of ambulatory surgery. A prospective study was undertaken in order to compare (adeno)tonsillectomies performed on an inpatient and outpatient basis. 104 patients underwent day surgery (adeno)tonsillectomy. 88 patients were treated as inpatients, but would have met the selection criteria for ambulatory surgery if an exception had been made in relation to travel distance. Tonsillectomy is an operation with high postoperative morbidity. Our study shows that patients undergoing day case surgery had better sleep, better oral intake and had less pain during the first postoperative night. The majority of the inpatients considered tonsillectomy performed as day case surgery less tolerable. With adequate information and patient selection, our study showed that most patients prefer day surgery. Questioned two weeks postoperatively, 92% of the patients preferred tonsillectomy performed as a day case procedure. Use of day surgery may improve health care efficiency. At the same time, it may improve quality of care for the patients.

Ambulatory laparoscopic cholecystectomy was attempted using a new anaesthetic regimen in 50 patients. 46 patients were discharged 3-5 hours after operation, four were admitted to and remained in hospital for 1-5 days, one for psychosocial reasons, one because of emesis and two because of extended surgery. 45 of 46 ambulatory patients were generally satisfied after having experienced ambulatory cholecystectomy. Postoperative pain and nausea were moderate. Only 24% needed parenteral opioids postoperatively, and only 30% needed anti-emetic treatment. One woman suffered unacceptable pain and discomfort during the first two days at home, and would not prefer to have ambulatory treatment (questionnaire). Four patients were readmitted. Two had a forgotten stone in the common bile duct and underwent ERCP to extract the stone, without further complications. The third had a clip occluding the common bile duct. She was reoperated on in order to remove the clip and insert a T-tube in the common bile duct. Finally one woman was readmitted because of abdominal pain and vomiting, of which we never found the cause. She recovered spontaneously. Even though serious complications associated with biliary surgery were unavoidable in this ambulatory series, we have documented that patients can be operated on safely in this way. Most patients were very content, and experienced much less postoperative discomfort than they had expected.