Chinese expert guideline on standardized process and standards of ambulatory surgery for inguinal hernia (2023 Edition)

Definition and Evolution of Day Surgery Day surgery, also known as ambulatory surgery, was initially proposed by the British pediatrician James H. Nicoll in the early twentieth century. It refers to a surgical model where "patients undergo admission, surgery, and discharge within 1 day, excluding outpatient surgeries performed in clinics or hospitals." In brief, it condenses traditional surgeries requiring multiple days of hospitalization into a 24-h period. The most widely accepted international definition was established by the International Association for Ambulatory Surgery (IAAS) in 1995, which proposed that "Patients undergo surgery or procedures and are discharged on the same day, excluding those performed in clinics or outpatient settings." In addition, patients requiring overnight admission are referred to as "day surgery–delayed recovery patients." In 2013, the China Ambulatory Surgery Alliance (CASA) officially joined IAAS, indicating a more distinct concept and a new phase for the development of day surgery in China. In 2015, CASA introduced the Chinese definition of day surgery: "Day surgery refers to surgeries or procedures completed between admission and discharge within 1 day (24 h)." In addition, two supplemental agreements were clarified: Firstly, day surgery refers to planned surgical procedures for patients and operations, excluding outpatient surgeries; Secondly, concerning patients with delayed hospitalization for day surgery, it pertains to special cases where hospitalization is postponed due to the patient's medical condition, with a maximum stay shorter than 48 h.[1] In 2022, the National Health and Family Planning Commission of the People's Republic of China issued the "Interim Quality Management of Day Medical Care in Medical Institutions," defining day medical care as a service model providing a complete inpatient process within 24 h while ensuring medical quality and safety. The guidelines propose basic requirements for organizational development, system standards, and process management, and specify the supervisory responsibilities of health administrative departments in day medical care quality management. In recent years, China has further integrated its day surgery practices with international standards, and the concept of "same-day surgery" has been widely accepted: Optimizing and reengineering the service process of daytime surgery, changing the traditional overnight mode of daytime surgery in China, and integrating the individualized enhanced recovery after surgery (ERAS) principles. It shortens the previous 1-day hospitalization for day surgery to the same-day admission, surgery, and discharge. Development and Current Situation of Inguinal Hernia Day Surgery Both adult and pediatric inguinal hernias are common diseases worldwide. In 1955, Dr. Farquharson from the Edinburgh Hospital reported successful cases of adult hernia repair using the day surgery model in "The Lancet" journal. In the 1980s, Wuhan Children's Hospital implemented high ligation of hernia sac for pediatric hernias, initiating early explorations of day surgery. At the end of the twentieth century, Beijing Chaoyang Hospital performed tension-free inguinal hernia repair, aiming to alleviate the difficulty of hospitalization. It began to explore inguinal hernia day surgery and gradually began to set up day operating rooms, day observation beds, and day wards. Currently, the number of inguinal hernia day surgery performed annually nationwide ranks second among all day surgery categories (second only to cataract surgery), conducting day surgery for inguinal hernia repair has significant socioeconomic value. Day surgery for adult inguinal hernias mainly involves laparoscopic inguinal hernia repair (LIHR) and open inguinal hernia repair. For pediatric inguinal hernias, day surgery mainly includes laparoscopic and open hernia sac high ligation. Day surgery has the advantages of shortening the average length of hospitalization, reducing medical costs, and accelerating patient rehabilitation, which can effectively improve the utilization rate of medical resources, improve patient satisfaction, and alleviate the contradiction between medical supply and demand.[2] The operation of inguinal hernia repair in the way of day surgery has put forward higher requirements for operation, anesthesia, and perioperative management. However, at present, there is still a lack of standards, unified, and suitable for the conditions of our country, which is not conducive to the effect evaluation, quality control, and further promotion of day surgery. Given the increasing prevalence of day surgery for inguinal hernia repair in China, experts in hernia and abdominal wall surgery in China have formulated Chinese expert guidelines on the standardized procedures and standards of inguinal hernia day surgery by combining the literature and the actual situation in China, aiming to provide a better reference and basis for the establishment of the standardized procedures of inguinal hernia day surgery. Facility construction of inguinal hernia day surgery. Facility Construction of Inguinal Hernia Day Surgery Different from independent day surgery center abroad, in our country day surgery center is mainly affiliated with large medical institutions. Necessary medical resources including a special day operating room, postanesthesia care unit, medical bed, equipment and facilities, medical staff, etc., should exist in these medical institutions to ensure efficient development of day surgery. Hospitals can construct or reconstruct day surgery facilities according to actual conditions, providing convenient, fast, efficient, and safe medical service and environment. Inguinal hernia day surgery facilities should include a comprehensive service area (reception desk, admission, and discharge management, and operation waiting area), a day surgery area (independent day operating room or relatively fixed operating room), and a day surgery ward.[3] Demands of patients, surgeons, and other staff should be fully considered during design.[4] The Organization Management of Inguinal Hernia Day Surgery Organization structure and team building for day surgery management Hospitals should establish a day surgery quality management committee under the medical quality management committee and develop work responsibilities. The committee periodically organizes meetings of various members under the hospital's authorization to study major management decisions related to day surgery and coordinate the cooperation of relevant departments.[5] The main responsibilities include (1) patient assessment system, follow-up system, medical staff training system, disinfection and isolation system, etc.; (2) establishing a selection mechanism for day surgery patients, diseases, and technologies in the institution, as well as a review and authorization management mechanism for medical staff, and organizing its implementation; (3) organizing the monitoring, early warning, analysis, feedback, and evaluation of day surgery quality in the institution, publishing relevant information on day surgery quality in the institution on a regular basis; and (4) formulating plans and organizing the implementation of continuous quality improvement plans for day surgery in the institution. The day surgery team is the foundation for conducting day surgery. It consists of a multidisciplinary and multisectoral team of medical staff, including anesthesiologists, surgical specialists, day ward physicians, nursing staff, and day surgery managers. The functions of the doctors are divided into outpatient, ward management, surgery, anesthesia, etc.; the nursing positions include appointment scheduling, health education, ward management, operating room collaboration, and postoperative follow-up.[5-7] The management team needs to develop rules for the operation of day surgery, pay attention to the operation status of day surgery at any time, identify problems, and coordinate timely handling. The head of the day surgery center and the head nurse are responsible for daily management.[7] Accreditation system Patients undergoing inguinal hernia day surgery have a short hospital stay, a fast turnover rate, and streamlined procedures. While improving operational efficiency, it is bound to increase medical risks. The establishment of an admission system is an important guarantee for reducing the risks of day surgery. The admission system for inguinal hernia day surgery should include the surgical procedure admission, patient admission, and surgeon admission. Operation type access For inguinal hernia day surgery, it is recommended to choose the surgical procedures that have minimal interference with the physiological functions of the body, low surgical risk, short operation time, low expected blood loss, few postoperative complications, mild postoperative pain, low incidence of nausea and vomiting, and discharge within 24 h after surgery.[7] The approval of the hospital's day surgery management committee is required before the operation can be carried out. The access and selection of inguinal hernia day surgery procedures are described in the "Surgical Procedure" section. Patient access Refer to the "Patient Selection Criteria" section. Surgeon access The surgeons who carry out day surgery must be approved and authorized by the hospital's day surgery management committee to perform day surgery at the corresponding level. Continuous technical ability reevaluation and reauthorization of surgeons are implemented, and dynamic management of surgeon qualifications is implemented. Surgeon access standards: (1) possessing a high-level attending physician or above title; (2) proficient in the corresponding surgical techniques of hernia surgery, with rich experience,[8] able to handle related complications and various emergency situations; (3) possessing good doctor–patient communication skills; and (4) abiding by the day surgery management system. Operation process and management The operation process and management of inguinal hernia day surgery include steps such as outpatient surgery, anesthesia outpatient, surgical appointment, preoperative education, admission for surgery, postoperative observation, discharge, and postoperative follow-up.[5-7] The operation process of inguinal hernia day surgery can be roughly divided into two modes: (1) patients complete preoperative examination and anesthesia evaluation in the surgical outpatient department, and then make a reservation for hospitalization in the day surgery center on the day of the surgical appointment. After completing the surgery and observation, they are discharged within the same day or within 24 h; and (2) patients go to the surgical outpatient department for consultation and then make a reservation for hospitalization in the day surgery center. Preoperative examination and anesthesia evaluation are completed on the day of admission, and surgery is scheduled for the next day. After surgery observation, patients are discharged within the same day (within 24 h). Each day surgery center can choose a suitable operation mode based on its own conditions and situation, and both modes belong to the operation process of inguinal hernia day surgery. During the operation process of inguinal hernia day surgery, it requires support and cooperation from multiple departments within the hospital, with team members coming from multiple disciplines and departments. Therefore, it is necessary to establish relevant work systems and job responsibilities for each position, and regularly organize relevant personnel to study and improve communication channels between different positions. Problems found during practical work should be communicated and resolved promptly.[7] Operation mode The management of day surgery shows differentiated and diversified characteristics. Currently, the main management modes in China are centralized management and centralized treatment (centralized mode), as well as centralized management and decentralized treatment (integrated mode). The previous decentralized management and decentralized treatment mode is not recommended due to its lack of unified management and quality control. The centralized management and centralized treatment (centralized mode) refers to setting up a day surgery center with independent wards and operating rooms, where patients from multiple departments are collected and managed in an integrated manner, including concentrated admission, concentrated surgery arrangement, and concentrated follow-up. The centralized management and decentralized treatment (integrated mode) refer to each department arranging a certain number of beds as day surgery beds, sharing the hospital's operating rooms. During the hospitalization period, patient management is completed by the ward medical staff, while the day surgery appointment scheduling and follow-up are uniformly completed by the day surgery management department. Both modes have their advantages and disadvantages. The centralized mode facilitates unified management and homogenization of quality control, while the integrated mode can maximize the utilization of limited bed and operating room resources. The choice can be based on the hospital's organizational structure and actual operating conditions. Operation status analysis, benefit evaluation, performance management, and patient satisfaction survey Analyze the operation volume, efficiency of medical resource utilization, and medical cost of day surgery to understand its operational status, further evaluate its social and health economic benefits, and timely detect and address issues in the operation process. During the operation of day surgery, an incentive mechanism can be established based on the actual operation situation of the hospital to promote the development of day surgery. Medical institutions should mobilize medical staff to actively carry out day surgery, and take the quality management of day surgery in departments and medical staff as the basis for doctors' regular assessment, promotion, and other work. Patient satisfaction surveys can promote the improvement of day surgery operation processes. Generally, third-party agencies are entrusted to carry out the survey. To reduce interference factors, it is recommended to survey satisfaction after discharge, preferably 1 month after discharge. The survey content includes satisfaction with medical process, satisfaction with treatment effect, satisfaction with the service attitude of medical staff, satisfaction with doctor–patient communication and discharge guidance, etc.[5,7] The Implementation of Day Surgery for Inguinal Hernia Patient selection criteria When selecting patients, apart from meeting the surgical indications, one must also consider the surgical indications, such as the absence of fever, no inguinal region infection, American Society of Anesthesiologists (ASA) class ≤ II, etc.[8] Additionally, patients should adhere to the requirements of the day surgery operating procedures. The patients classified as ASA III or above can also undergo day surgery, as long as their comorbidities are stable and have undergone a rigorous evaluation and preparation by an anesthesiologist. Age alone should not be the sole determinant of eligibility for day surgery. Instead, it should be assessed comprehensively considering the type of surgery, the patient's overall condition, anesthesia methods, the severity of comorbidities, and the control of comorbidities. However, this should be clearly specified in the clinical pathway documented by the medical department.[7,9] The indications for day surgery for inguinal hernia include simple inguinal hernias, including unilateral and bilateral indirect hernias, direct hernias, femoral hernias, and uncomplicated recurrent inguinal hernias. Contraindications include incarcerated hernias, strangulated hernias, and cases where anesthesia assessment deems day surgery inappropriate.[9] Additionally, adult supervision at home is required for patients after discharge.[7,9] Selection of surgery method The tension-free hernia repair using repair materials, which is recommended for adult patients with inguinal hernia, can be categorized into two types: open inguinal hernia repair and LIHR.[10,11] Open inguinal hernia repair includes tension-free repair techniques such as the flat mesh repair method, plug and patch technique, and preperitoneal space repair method.[12] Currently, synthetic hernia repair materials are widely applied in clinical practice such as polypropylene, polyester, and polytetrafluoroethylene.[13,14] Additionally, decellularized extracellular matrix biological patches and synthetic absorbable materials, as a category of absorbable and degradable materials, have become increasingly prevalent in clinical applications of inguinal hernia repair surgery.[15-19] Biological patches have comparable recurrence rates with synthetic patches in terms of both short- and long-term recurrence rates, and they are considered as an alternative in potentially contaminated fields.[20,21] Of course, absorbable and degradable patch repairs are mainly performed for young adults who are concerned about foreign body sensations and infertility. On the other hand, the cost of biological meshes has been decreasing in China over last a few years. The surgical methods for pediatric inguinal hernia mainly include laparoscopic surgery and open surgery with high ligation of the hernia sac. Each surgical method has its specific indications. Experienced specialists can follow the principle of "individualized treatment" to select the appropriate surgical method and hernia repair materials based on the patient's specific condition.[22] The preoperative examination The preoperative examination items for inguinal hernia day surgery are the same as those for traditional inpatient surgery. According to the requirements of anesthesia assessment, all preoperative examinations should be completed before the scheduled surgery date (the specific time limit may vary according to the requirements of the anesthesiologist, but should not exceed 1 month at most), to timely complete the preadmission assessment, ensuring the accuracy and timeliness of the examination results.[8] If any abnormalities or changes in the patient's condition are found during the examination, further targeted examinations or reexaminations should be arranged for related assessment of the condition changes. Preoperative anesthesia assessment For patients with inguinal hernia who require day surgery, a formal preoperative anesthesia assessment is necessary to ensure patient safety and avoid surgical delays or cancelations due to inadequate evaluation and preparation. It is encouraged to establish a preanesthesia assessment clinic (PAC) while alleviating the patient's anxiety toward surgical anesthesia.[22] Please refer to the "Expert Consensus on Anesthesia for Day Surgery" developed by the Chinese Society of Anesthesiology for details of the assessment.[8] Venous thromboembolism (VTE) and bleeding risk assessment Clinicians should assess the risk of VTE and bleeding in patients with high incidence of VTE in patients with daytime surgery for inguinal hernia, and consider whether and how VTE prevention is needed based on the assessment results. For patients who take antithrombotic drugs for a long period of time and require surgical procedures, clinicians and anesthesiologists should evaluate the patient and decide on a perioperative medication regimen based on the assessment results.[23] For the content of the assessment, please refer to the "Chinese Guidelines on Perioperative Thrombosis Prevention and Management in General Surgery" developed by the Chinese Society of Surgery of the Chinese Medical Association.[24] Scheduling of surgical appointments Surgical appointment scheduling is a key link in the control of resource allocation in the operating room: (1) checking patient information and examination results to ensure that the patient meets the admission requirements for day surgery; (2) familiarizing with the physician's surgical plan; (3) knowing the functional arrangements of the operating room to guarantee the effective use of surgical resources; (4) initiating priority scheduling for day surgery; (5) accurate information entry; and (6) carefully conducting audits to ensure that the surgical schedule is accurate.[7] Prehospitalization education Health education can reduce the psychological stress response of surgery to patients, shorten the hospitalization time of surgical patients, save costs, and reduce patient anxiety and postoperative pain. The contents include (1) surgery and anesthesia mode, possible complications and solutions; (2) drug withdrawal plan for patients taking medication, such as discontinuation of rifampicin and anticoagulant or alternative treatment, smoking patients to quit smoking 2 weeks before surgery; (3) informing patients of the program of fasting and abstaining from eating and drinking[8]; and (4) informing the time of admission, the place of hospitalization, the time of surgery, the preparation of medical paperwork and information, the patient's own preparations, and the accompaniment of family members. Educational methods included graphic materials, oral presentations, video education, etc. The principle was to use methods that were easy for patients to accept and had a good effect. Preoperative reassessment After admission to the hospital, preoperative reassessment is required to determine whether the patient meets the criteria for day surgery, and cases that do not meet the criteria for day surgery are eliminated and transferred to the appropriate specialty ward for further treatment according to their condition. Reassessment is jointly initiated by the surgeon and anesthesiologist, and is an important step in reducing the risk of day surgery and ensuring that patients are eligible for day surgery for inguinal hernia. Preoperative reassessment and patient selection in the outpatient clinic are two separate processes, which should serve to validate and complement each other. Surgery and operating room management At the end of the operation, the surgeon and anesthesiologist should again judge whether the criteria for day surgery are met according to the specific conditions of the patients' operation; If any accident occurs during the operation, it should be handled in time, and transferred to a specialist ward (if necessary, it can be transferred to the intensive care unit) to continue observation, and should not pursue the day surgery while neglecting the safety of the operation;[25] the surgical operation should be performed based on the principles of minimally invasive surgery and precise surgical concepts, to reduce surgical trauma. All personnel involved in the daytime surgery process should be familiar with the operation standard of daytime surgery, and the items needed in the operation process should be fully prepared before the operation. Anesthesia Open inguinal hernia repair can be performed under local anesthesia.[26] Local anesthesia primarily includes methods such as local nerve block anesthesia, local regional block anesthesia, and surface infiltration anesthesia. Local nerve block anesthesia targets the iliohypogastric nerve, ilioinguinal nerve, and genitofemoral nerve in the inguinal region. This also encompasses high-level nerve block anesthesia guided by ultrasound for the above nerves. Intensive local anesthesia, intravenous general anesthesia, or intralesional anesthesia is required for complex open inguinal hernia repair or when local anesthesia proves ineffective. General anesthesia is required for LIHR. The specific anesthesia method required can be tailored by an anesthesiologist based on the individual patient's condition. Management of postoperative complications Pain management: Postoperative pain is a major factor in delayed discharge, and effective analgesia can facilitate recovery.[27] If the postoperative visual analog scale (VAS) pain score exceeds three points, intervention is necessary. Long-acting analgesic anesthetics such as ropivacaine and bupivacaine with lidocaine can be used in open inguinal hernia repair to implement nerve block anesthesia, which can effectively extend postoperative analgesia and provide a better pain experience for patients. Pain management, primarily through oral and local analgesia, is the mainstay, with a recent emphasis on the combined use of nonopioid and opioid medications to reduce opioid consumption. Nonsteroidal anti-inflammatory drugs are recommended as foundational medications in the United States and several European countries. If not contraindicated, non-opioid medications are preferred, and selective cyclooxygenase-2 inhibitors in tablet form are recommended as continuous oral analgesics.[28] For inguinal hernia day surgery, due to minimal trauma and lower pain intensity, the above analgesics typically yield satisfactory results, and patient-controlled analgesia is generally not required. Prevention of postoperative nausea and vomiting (PONV): PONV are the second leading factor in prolonging hospitalization for day surgery patients.[29] Severe PONV can affect feeding, wound healing, and delay postoperative discharge. Factors influencing PONV are diverse. For patients at moderate risk of PONV, one or two intervention measures should be adopted for prevention. For high-risk patients, a combination of therapy (≥2 intervention measures) and/or multimodal therapy is needed for prevention. Postoperative care Day surgery for inguinal hernia has relatively fast recovery, allowing patients to quickly return to normal life after surgery. While postoperative care is generally less challenging, attention should still be given to the following: (1) closely observe changes in the patient's condition and provide effective management; (2) after the patient regains consciousness, encourage a comfortable position and early oral intake; (3) motivate early ambulation, guiding patients through a gradual postoperative activity progression; (4) educate patients to understand pain, learn the VAS scoring method, and intervene when the VAS score exceeds three according the medical advice; and (5) train and educate family members to improve the self-care skills of patients and their families.[30] Postoperative contingency plan The postoperative emergency plan for day surgery is designed to urgently deal with emergencies that occur during the patient's hospitalization and ensure the patient's medical safety. Medical institutions should establish daytime medical emergency plans, improve the mechanism of consultation and referral, clarify the mechanism of daytime medical rescue resource allocation and emergency deployment, and ensure that the rescue equipment and medicines of each daytime medical unit are available at any time. Institutions also need to strengthen emergency drills to ensure that the daytime medical emergency plans can be implemented smoothly. Postoperative patients with emergencies need to be handled according to this plan: (1) notify the attending surgeon or assistant to inspect the patient, evaluate the condition, and dispose of the patient accordingly; (2) if the patient's condition does not allow for discharge within 24 h postoperatively, the attending surgeon should arrange for the patient to be transferred to a specialized ward for further observation and treatment; and (3) report to the person in charge of the day surgery center to coordinate the treatment at.[6,7] Discharge criteria and predischarge assessment Discharge criteria: (1) the patient's vital signs were stable, conscious, and clearly cognizant; (2) pain was tolerated or controlled by oral medication; (3) there were no abdominal symptoms or signs, fever, nausea, or vomiting; (4) normal walking with medical advice for discharge; and (5) the patient and family members were prepared for discharge and were accompanied by an adult family member for discharge. The assessment was performed 2 to 3 h before the decision to discharge the patient. For assessment at discharge, patients can be evaluated by the postanesthesia discharge score (PADS) to assess whether they meet the criteria for discharge, and they can be discharged when they meet the PADS criteria. Discharge required the fulfillment of two aspects: (1) a PADS score of ≥9; and (2) an adult with mobility, accompanied by a healthy adult family member. Oral analgesics were routinely carried out at discharge, and relevant precautions and contact information were communicated. The condition of patients undergoing day surgery should be reassessed before discharge, and patients with unstable conditions should be kept in the hospital for a longer period of observation. Day surgery should set up the necessary exit mechanism, for the diagnosis and treatment process found to be unsuitable for the daytime ward process the case should be withdrawn from the daytime surgery process, and arranged to enter the specialized wards for further diagnosis and treatment. Discharge rehabilitation guidance and follow-up of discharged patients Medical and nursing care jointly formulate the items and contents of postdischarge rehabilitation guidance; professional nurses record the condition of discharged patients and provide rehabilitation guidance. The guidance includes postdischarge diet, activities, medication, reporting of abnormalities, and a reminder of follow-up consultations, etc. The integrated community linkage service is adopted to publicize the knowledge related to rehabilitation activities through multichannels. Patients should be informed in writing of the need for outpatient review after discharge and observation of postoperative recovery; if sudden symptoms occur after discharge, contact the Day Surgery Center or go to the emer