Most laparoscopic hysterectomy procedures require an overnight or sometimes 2-night convalescence. That's not the case here at the Women's Specialty Surgery Center of Dallas. At our free-standing, 4-OR surgical center, we perform minimally invasive hysterectomy with as little as a 4-hour recovery-to-discharge time. We offer laparoscopic supracervical hysterectomy (LSH), which lets women keep their cervixes, or total laparoscopic hysterectomy (TLH). These procedures appeal to active women with busy lifestyles who'd rather tolerate excessive bleeding longer than necessary than take the time to recuperate from surgery. Here are the keys to adding outpatient LSH and TLH and helpful hints for day-surgery discharge. With the right staffing, preparation, counseling and recovery strategies in place, you too can offer the most commonly performed gynecologic operations as outpatient procedures.

Patient selection and preparation
Not all patients are appropriate candidates to have their hysterectomy performed on an outpatient basis. Here is the profile we look for in an outpatient LSH or TLH patient:

It's crucial to have your surgeons and nurses prepare and counsel patients before, during and after the day of surgery. This preparation starts with the office consultation, where the surgeon should present the LSH or TLH to the patient as a day-surgery procedure. A few days before the scheduled surgery, have a nurse from your facility call the patient at home to take her medical history and current medications, as well as perform pre-operative teaching. At this time, the nurse also reviews events as planned for the surgery and discharge. Ideally, the patient should fill her post-operative prescriptions from the physician's office before the day of surgery. When she arrives, have your nurses adopt a friendly and relaxed tone in the pre-operative area to comfort the patient and provide open communication. Warming blankets and gowns are another great way to instill a feeling of comfort during the patient's stay.

Anesthesia and pain
Post-operative nausea is one of the primary reasons why hysterectomy patients may face a delayed recovery and discharge. To improve the patient's ability to be discharged and for their comfort, work with your anesthesia providers to prevent post-operative nausea and vomiting. Here are the pre-emptive actions our anesthesiologists take:

• At induction: 4mg to 10mg IV dexamethasone (Decadron) and 10mg IV metoclopramide (Reglan).
• Before extubation: 8mg IV ondansetron (Zofran).
• Patients with a history of PONV receive the anti-emetic aprepitant (Emend) 40mg within 3 hours of anesthesia induction.
• Avoid preloading with crystalloid during the first half of the case. This can cause cerebral edema while the patient is in the steep Trendelenburg position, which exacerbates post-op nausea and somnolence.
• Avoid using long-acting narcotics, such as fentanyl and morphine, to decrease somnolence. Instead, use short-acting systemic agents, such as sufentanil (Sufenta), and long-acting local anesthesia.
• Give ketorolac (Toradol) 30mg IV before extubation or in PACU for additional pain control.
• Give the first dose of pain medication prescribed for home use in PACU to ensure it is well tolerated by the patient.

PACU pearls
Although we're able to send them home an average of 5 hours after the completion of their operations, laparoscopic hysterectomy patients require lots of TLC in the post-anesthesia care unit to make this goal a reality. Start by removing the Foley catheter in the operating room before extubating the patient, as this seems to aid in the need to void early, which is the desired effect. Have patients recover on a stretcher with the head elevated at a 45- to 75-degree angle to reduce cerebral edema, which can be caused by the steep Trendelenburg position used during laparoscopic hysterectomy. We let our patients sleep quietly for about an hour, then try to get them to ambulate as early as possible, attempting their first void at the 2-hour mark.

During the patient's in-center convalescence, have your nurses reiterate their pre-operative counseling. They should also make post-operative follow-up phone calls 24 hours after discharge. Send post-op questionnaires to patients' homes to gather data about their experiences. Tracking this data is imperative, as it offers reassurance to the patient, enhances surgeon confidence and helps you monitor your outcomes.

Staffing is key
We cannot overstate the importance of having a highly skilled, dedicated and efficient staff in ensuring the comfort and quick recovery times of your laparoscopic hysterectomy patients. Our teams consist of registered nurses, surgical technicians, sterile processing techs and PCTs (patient care technicians). All of our nurses are ACLS-certified and all of our nurses and techs are CPR-certified.

When hiring, choose nurses who are warm, friendly and highly skilled (we prefer a minimum of 3 years of experience). Even though we do LSH and TLH on an outpatient basis, they're long procedures (70 to 90 minutes) with long recovery-to-discharge times (3 to 6 hours). It's imperative that your staff work together as a well-oiled machine to turn over rooms in less than 10 minutes. Our average turnover time is around 7 minutes, which keeps the surgeons happy and even has us running ahead of schedule sometimes. Here are some of our turnover tips:

• Burritos. For each case, we make a "burrito" — linen with a new trash bag and linen bag wrapped inside like a burrito.
• All hands on deck. Everyone who's available goes to the room to assist in turnover. We use the call button to let everyone know the case is over and to let PACU know we're coming out of the room.
• Anesthesia supplies. We have a dedicated person to change out the anesthesia circuits and restock the anesthesia carts between cases.
• Case carts. We keep case carts outside the room so that opening for the next case is faster.

All about the patient
Hysterectomy's shift from the inpatient to the outpatient setting is great news for ambulatory surgery facilities and surgeons, but most importantly, it's great news for patients. Our patients — active women with careers, carpools and other obligations that have them seeking shorter surgical recovery times — find great comfort in knowing that laparoscopic hysterectomy is a safe alternative to traditional open surgery that improves their post-operative quality of life by letting them go home on the day of surgery.