With the recent advances in modern medicine and medical technology, an increasing number of physicians are able to perform more advanced and complex surgical procedures in their offices. Although the list of these procedures continues to grow everyday, most of the surgical procedures performed in a doctor’s office involve some form of sedation and analgesia in order to lessen the pain and anxiety of the surgery. Regardless of whether it is a simple mole removal, breast augmentation and reduction, liposuction, hernia repair, or knee arthroscopy, a rapidly growing number of patients prefer to have these surgeries performed in a doctor’s office rather than in hospitals or ambulatory surgical centers. As we saw in
Chapter 2, patients and surgeons make their choices based on issues of cost, convenience, and scheduling. When one looks at the statistics, it appears that over the next few years more complex procedures are likely to become commonplace. Indeed, some office-based procedures are of such degree of complexity that they involve general anesthesia (GA) to provide a total loss of consciousness in the surgical patient (
1). This becomes an added burden to all health care providers involved; the desire to keep up with the trends and advances, yet maintain the traditional standard of providing a safe, pleasant, and comfortable experience for the patient.
According to the American Society of Anesthesiologists’ (ASA) Guidelines for Office-Based Anesthesia, it is estimated that in 2005, ten million procedures were performed in doctors’ offices—twice the number of office-based surgeries performed in 1995. Furthermore, while 80% of surgeries are currently performed in hospitals or ambulatory surgical centers, we are seeing the same trend in the movement to the office-based setting as we saw 20 years ago with the shift from the inpatient to the outpatient setting. Currently, approximately one out of ten surgeries are performed in a doctor’s office.
While it is nearly impossible to list the myriad surgical procedures performed in any number of subspecialist physician offices, this chapter will attempt to cover some of the more common procedures. Many of the office-based procedures would benefit equally from the available methods of anesthesia (i.e., local, regional, monitored anesthesia care [MAC], GA—see
Chapter 7) and will vary from patient to patient depending on a number of situations and variables.
With office-based surgical procedures, as with hospital or ambulatory surgical center-based procedures, patients will need to undergo a detailed history and physical examination. All comorbidities, medications, including over-the-counter and herbal preparations, allergies, problems with previous anesthesia, and psychosocial details will need to be factored into the anesthetic plan. Finally, the anesthesiologist may decide that a patient’s comorbidities and other factors preclude him from a surgical procedure in an office setting.
When the decision has been made to proceed in the office setting, it is crucial to insure that all necessary monitors, airway adjuncts, anesthesia equipment, and other devices are present and that they are in good operating condition before beginning a procedure where any type of sedation or anesthesia will be administered.
Table 11.1 and
Box 11.1 are essential items for the office-based setting. A comprehensive list can be found in
Chapter 10. There will be individual variations based on the specific procedure, the facility, and the type of anesthesia planned.