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Ambulatory Gynaecology

Ambulatory gynaecology represents an alternative approach to consultation, waiting for investigations like U/S scan then placement on waiting lists for conventional surgical interventions whether day surgery or inpatient.  It may be delivered within a one stop setting and/or closer to home in satellite units or within office environment and where appropriate in nurse led clinics while patients are awake and able to interact with the practitioner. 

Technological advances drove the expansion in ambulatory gynaecology.  More and more procedures traditionally requiring inpatient are now being offered as ambulatory due to flexibility, convenience and patient choice particularly for those wanting to avoid general anaesthetic, enjoy quicker treatment/recovery (minimal time off work), closer to home treatment/reduction in hospital visits/shorter care pathway, less invasive treatment (avoiding scars of intra-abdominal surgery), treated within a more familiar, welcoming/less threatening outpatient environment with ability to interact with practitioner let alone the potential cost savings involved.  There may be some discomfort but this is usually minor and short lived. Various protocols for analgesia/local anaesthetic have been developed and integrated into the pathway.  Patient selection remains a key however.

Laparoscopic sterilisation may now be replaced with hysteroscopic/transcervical (under local or no anaesthetic and no incision needed)  placement of small inserts into the fallopian tubes [ESSURE, Conceptus] that induce benign fibrotic reaction/blockage over a period of three months.   Submucous fibroids, polyps (small or larger), intra-uterine septum and synaechae may also be similarly treated/resected within the outpatient setting using, where appropriate, ambulatory hysteroscopic approaches like a resctoscope or snare [Cooke] or mechanical morcellation such as Myosure [Hologic] or Bagetti shaver [Storz] or Versapoint [Gynaecare] etc. Endometrial ablation as an alternative to hysterectomy for women with menorrhagia/dysfunctional uterine bleeding may now also be offered within the ambulatory setting.  Various endometrial ablation techniques/devices have already been in use for this purpose with success rates in excess of 85-90%, e.g. Novasure [Hologic], thermachoice [Gynaecare], hydrothermablation [Boston] etc.

Ambulatory gynaecology may also be applied to more specialised areas within gynaecology like, for instance, urogynaecology where procedures like cystoscopy, botox treatment for overactive bladder, bladder installation for interstitial cystitis are some examples of what may be offered.  Ovarian Cyst aspiration may also be carried out, where appropriate, as ambulatory procedure transvaginally under U/S guidance and for many years oocyte collection/in-vitro fertilisation (reproductive medicine) has already been carried out as ambulatory or under sedation.

As such, ambulatory gynaecology represents an opportunity to transform the way care is delivered within gynaecology in partnership with patients within an outpatient setting and in a more cost-effective way compared to traditional approach of in-patient treatment giving patients more choice and flexibility besides being in keeping with the strategic vision set in the NHS delivery plan.  In Liverpool, ambulatory gynaecology may be also more appealing to patients living in the periphery (e.g North Liverpool) or wanting to be treated relatively closer to home rather than travelling to centre Liverpool Women's Hospital.

Some challenges need overcoming in areas like training, flexibility in working pattern and integrating ambulatory with other care pathways (e.g. rapid access), cost of performing combined procedures (e.g. ablation and sterilisation) that may not be offset by current tariff rules paying for only one etc.  Local tariff negotiations may be a key for combined procedures tariff issues given the cost savings achieved compared to in-patient treatment.  Review of training curriculum is another key given the need for modern gynaecologists and specialised nurses to now acquire a range of new skills, functioning in a multidisciplinary way, keep up to date/regularly auditing results/maintaining quality.  Dedication to improve patient care and the way it may be delivered is the real drive for change.

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