Ambulatory surgery: an organisational and cultural revolution, a social and political challenge

I cannot remember the name of the rabbi who called out—maybe it was in fact Woody Allen: ‘Does anyone have a question, because I have the answer’. No doubt this question seems at first glance a paradox or absurd humour. Could one actually imagine solving a problem before having stated it? Of course not. But could one imagine an answer to a non-question? No more. To a formulated question, an answer is possible, probable and maybe even certain. The answer is more certain than the question. The questioning is therefore undoubtedly the most hazardous and essential moment of the answer. Why this rather philosophical introduction and how does this concern our subject? All present here already know the answer: The answer is ambulatory surgery. But ambulatory surgery is the answer to what, to which questions? Nowadays the paternity of modern ambulatory surgery is classically attributed to James Henderson Nicoll a surgeon from Glasgow which, as every Scot knows, is in Scotland. In 1909, Nicoll published an article in the British Medical Journal about his experience with 8988 operations performed as day surgery cases [1]. What do we know about this experience that related to a wide range of operations performed on children, almost half of them less than 3-years-old and a fair number of them less than 1 year. Which problems was the development of this important healthcare practice supposed to solve? Nicoll explained it in his article: ‘Infants and young children in a ward are noisy and not infrequently malodorous. Children rest more quietly and fare better in the arms of a mother of average intelligence than anywhere else’. Finally, the Scottish surgeon continues: ‘I have no alternative to the opinion that the treatment of a large number of the cases at present treated as inpatients constitutes a waste of the resources of a children’s hospital or a children’s ward’. Taking into account his experience with children, Nicoll estimated that, as far as the adults are concerned, various operations and particularly cures of hernia, lead to hospitalisations that, according to him, were too long and could be reduced to... less than a week. Unfortunately we don’t know much—if anything— about the possible means, and in particular about the organisational model implemented by Nicoll. All that Nicoll tells us, is that the children were operated in the out-patient department and went home in their mother’s arms. The mothers were given nursing advice and apparently, everything went well. When he gave this presentation, at a meeting of the British Medical Association, most of his distinguished colleagues participating in the debate entirely agreed with him and claimed that they shared the same practice. Under these circumstances, it is at the very least curious that no report whatsoever has reached us relatE-mail address: [email protected] (C. De Lathouwer)