Ambulatory or outpatient surgery is applicable to relatively few chapters in this Atlas. However, the repair of inguinal, femoral, and small umbilical hernias, breast biopsies, excision of skin tumors, and many plastic procedures are commonly performed in an ambulatory setting. In addition, many gynecologic procedures as well as certain orthopedic, otolaryngologic, and other procedures are performed in this area. The decision for or against ambulatory surgery may depend on the facilities available, as well as on the presence of an in-house anesthesiologist, recovery room, and observational unit. If all of these are available, some surgeons will also perform minimally invasive or laparoscopic procedures. Many patients tend to feel reassured by plans for ambulatory surgery, which in the majority of instances does not involve hospital admission. Obviously, the guidelines for this approach may well be altered by the patient’s age and any changes in physical status.

The surgeon is responsible for making the specific decision for or against ambulatory surgery provided that the patient finds it acceptable. The attitude of the patient, the nature of the surgical problem, the depth of family support that will be available postoperatively, and the type of facility in which the procedure is to be performed must all be taken into consideration. Hospital guidelines usually indicate the procedures found to be appropriate and acceptable to that particular institution as defined in their credentialing of operative privileges and procedures. The surgeon may perform very minor surgical excisions in a properly equipped office and more extensive procedures in a freestanding facility or one associated with a hospital that provides anesthesiologists, equipment, and personnel competent to handle unexpected emergencies.

Since the general surgeon will depend upon the use of local anesthesia for many patients undergoing ambulatory surgery, it is important to be familiar with the limitations on the amount of each local anesthetic that can be safely injected. A review of the nerve supply to the area involved is advisable. Although reactions to local anesthetics are relatively uncommon, the signs and symptoms, which may include convulsive seizures, should be recognized, and preparation should be made for the early administration of some type of anticonvulsant.

Anesthesiologists tend to triage patients into several categories as defined by the American Society of Anesthesiologists (ASA). In ASA category I are patients who have no organic, physiologic, biochemical, or psychiatric disorders. The pathologic process being operated upon is localized and not systemic. In ASA category II, patients have a mild to moderate systemic disturbance caused either by the condition to be treated or by other pathophysiologic processes. Examples are mild diabetes or treated hypertension. Some would add all neonates under 1 month of age and all octogenarians. ASA category III includes patients with severe disturbances or disorders from whatever cause. Examples include those with diabetes requiring insulin or patients with angina pectoris. The presence of an anesthesiologist is essential in the majority of patients in ASA categories II and III.

Ambulatory surgery requires that the final physical evaluation of the patient by the surgeon be performed as near the date of the procedure as practical. Many ambulatory surgery centers start this process by having the patient fill out a checklist like those shown in figures 1 and 2. This information is reviewed by the surgeon, the admitting nurse, and the anesthesiologist. The patient is assigned to the proper category. ASA categories I and II patients are generally excellent candidates for ambulatory surgery, whereas ASA category III patients should be carefully selected in consultation with the anesthesiologist.