Gastrointestinal repair brings in new patients

(Editor’s note: This is the fourth story in a four-part series highlighting innovative outpatient surgery procedures. In the previous three issues, we’ve covered cosmetic procedures, pain management procedures, and sentinel node biopsy.)

New equipment that measures contractility of the esophagus, tests that measure stomach acidity, and a surgeon’s agreement to perform the procedure at the center were the main reasons Fremont (CA) Surgery Center began offering laparoscopic paraesophageal hernia repair with Nissen fundoplication.

"We have a very active gastrointestinal [GI] department, and we perform about 150 GI procedures per month," explains Debbie Mack, RN, MSN, director of nursing at the freestanding center. Manometry equipment that can measure the contractility of the esophagus combined with pH testing to determine the acidity of the stomach enables physicians to more accurately diagnose esophageal hernias, says Mack.

A general surgeon in the area who has a great deal of experience with laparoscopic hernia repair agreed to perform the procedure if the patient was appropriate for outpatient laparoscopic surgery. "We’ve been performing this procedure for four months, and it is always a 23-hour stay," says Mack.

At this time, her center is doing two to three laparoscopic Nissens each month, and reimbursement just covers costs. "As we increase the number of these procedures we perform each month, we should begin to make a profit," she adds.

At Promina DeKalb Medical Center’s day surgery center in Decatur, GA, the volume of six or eight Nissens per month is not only covering costs, but also generating a small profit, says Gwen H. Lyons, RN, CNOR, assistant director of surgical services. The hospital-based program has been performing the outpatient procedure since 1994.

Your facility’s mix of managed care contracts will determine whether the procedure generates a profit, especially at the beginning, Mack explains. Her program has some contracts that reimburse below cost, but there are others that reimburse more than the center’s cost; thus, Mack decided it was financially feasible to proceed with the service. Mack and Lyons suggest evaluating reimbursement levels from your current managed care contracts when you evaluate offering the procedure.

Any same-day surgery program that already is offering laparoscopic cholecystectomies should need very little new equipment, staffing, or training to offer the procedure, say surgery center managers.

As with any laparoscopic GI procedure, you must be prepared and equipped to perform an open laparotomy even though only 4% to 5% of laparoscopic hernia repairs require opening, says Jeffrey Ponsky, MD, director of minimally invasive and endoscopic surgery at the Cleveland Clinic Foundation. Freestanding surgery centers will need procedures in place to transport and admit the patient into a hospital postoperatively.

Two essential pieces of equipment include esophageal dilators and ultrasonic shears or scalpel, says Ponsky. The ultrasonic shears (available from U.S. Surgical in Norwalk, CT, and Ethicon in Somerville, NJ) cut and cauterize using ultrasonic energy rather than heat.

At a cost of $30,000, the ultrasonic equipment can be expensive for a center just beginning to build the laparoscopic hernia repair business, says Mack. Her center takes advantage of a program offered by U.S. Surgical that allows her to borrow the equipment on an as-needed basis. Surgery program managers can check with their manufacturers’ representatives to see if similar programs are offered in their area, she suggests.

"Once our volume increases, I may be able to justify purchasing the equipment, but not now," she explains.

Patient volume increasing

Patients who previously had to live with their conditions because they didn’t like the alternative of major surgery that requires a hospital stay are beginning to request the laparoscopic procedure, says Lyon.

Most patients with paraesophageal hernias are candidates for the surgery, but there are some exceptions, says Ponsky. The procedure is difficult to perform on a very obese patient because of the length of the trocars and instruments. Also, patients with upper abdominal scarring from multiple previous surgeries may not be appropriate because the scarring limits laparoscopic accessibility.

Also, "patients with pulmonary or coagulation difficulties are not good candidates for the laparoscopic procedure," he adds.

Training requirements for the surgery center staff are not extensive, says Mack. "We basically had our staff observe a procedure prior to assisting during a procedure."

The staff should be oriented to the instruments, positioning of the patient, and the procedure by the physician, suggests Ponsky. "Everyone should also observe a procedure before assisting," he adds.

Managers at DeKalb Medical Center’s outpatient surgery center not only visited other centers at which the procedure was performed, but nurses were sent to training courses offered by vendors who supply the equipment used for the procedure.

"Visit other surgery centers," Lyons suggests. "There is nothing more valuable than to see what works for other people. Site visits help you plan and prepare more effectively."