The purpose of this book is to introduce gynecologists and other clinicians to the principles and techniques of diag-nostic and therapeutic procedures for women that can be safely and efficiently carried out in a properly equipped office, freestanding surgicenter, or ambulatory surgical unit. Most of the procedures described in the following chapters can be performed under local anesthesia. These chapters include discussions of patient selection, patient counseling, and informed consent; the equipment required to perform the operation; a description of the surgical procedurę itself, including common technical and opera- tive difficulties; possible complications; and postoperatwe care.
Not all patients and not all surgeons are good candidates for ambulatory surgery. Each chapter identifies the factors that may exclude patients from ambulatory surgery, but surgeons must also decide whether they themselves are appropriate candidates for performing this kind of surgery. The best candidates are those who enjoy operating quickly and efficiently, who like organizing a u team approach" to providing operative care, and who are good at communi- cating with patients. The purpose of this chapter is to describe the principles, components, and organization of ambulatory gynecologic surgery.
Physicians, their patients, and all of us who pay for health care have become increasingly interested in ambu latory surgery over the past several years. During the 5 years from 1983 to 1987, for example, the number of surgicenters in the United States more than doubled to nearly 500, while the number of operations performed in them tripled to more than one million (1). Gynecologic procedures accounted for 37% of these operations, far more than any other category. If elective abortions are included, gynecologic surgery accounts for more than two- thirds of ambulatory procedures (2).
Ambulatory surgery is not confined to surgicenters. Se-lected operations are performed in physicians' offices, in hospital outpatient clinics, and in abortion and other specialized clinics. This book focuses on those procedures for women that are commonly performed in such settings. The equipment and techniques described can also be em-ployed in the traditional operating room. The intent of this book is not, however, to change surgical practice in hospi tal operating rooms, but to describe diagnostic and ther-apeutic procedures that can be safely and efficiently performed outside the hospital.
The most obvious advantage of the movement away from hospital-based surgery is a dramatic decrease in cost. The total cost of a diagnostic cervical dilation and uterine curettage with a one-night hospital stay in New York City in 1986 was $2637. The cost for the same procedure at the Manhattan Day Surgery Center was $275. In a 1985 US survey, a hospital tubal sterilization operation without an overnight stay averaged $1275, while the average for an office procedure was only $322 (3). Because stringent medical care cost-control programs are here to stay, sav- ings like these cannot be ignored by physicians, patients, or insurers. More and more procedures will be performed outside hospital operating rooms and clinicians must learn to work in these alternative settings.
Cost savings are not the only advantage to ambulatory surgery. Both patients and physicians will find that avoiding the hospital operating room saves them the un- certainty and anxiety that come with scheduling simple and complex, elective and emergency, local and generał anes- thesia cases in the same venue. Long delays caused by emergencies, unexpected complications, and slow sur-geons can be eliminated for the operations described in this book when they are performed in the office or surgicenter. Finally, ambulatory surgery is fun. It requires good techniąue, teamwork, and close communication among the surgeon, the staff, and the patient. It allows them all to participate actively in the surgical experience and to enjoy independence and self-reliance.