Telehealth Follow-up in Lieu of Postoperative Clinic Visit for Ambulatory Surgery.

Importance  Telehealth encounters can safely substitute for routine postoperative clinic visits in selected ambulatory surgical procedures.

Objective  To examine whether an allied health professional telephone visit could safely substitute for an in-person clinic visit.

Design  Prospective case series during a 10-month study period from October 2011 to October 2012 (excluding July and August 2012).

Setting  University-affiliated veterans hospital.

Patients  Ambulatory surgery patients who underwent elective open hernia repair or laparoscopic cholecystectomy during the 10-month study period.

Interventions  Patients were called 2 weeks after surgery by a physician assistant and assessed using a scripted template. Assessment variables included overall health, pain, fever, incision appearance, activity level, and any patient concerns. If the telephone assessment was consistent with absence of infection and return to baseline activities, the patient was discharged from follow-up. Patients who preferred a clinic visit were seen accordingly.

Main Outcomes and Measures  Percentage of patients who accepted telehealth follow-up and complications that presented in telehealth patients within 30 days of surgery.

Results  One hundred fifteen open herniorrhaphy and 26 laparoscopic cholecystectomy patients had attempted telehealth follow-up. Seventy-eight percent (110) of all patients were successfully contacted; of those, 70.8% (63) of hernia patients and 90.5% (19) of cholecystectomy patients accepted telehealth as the sole means of follow-up. Complications in the telehealth patients were zero for cholecystectomy and 4.8% (3) for herniorrhaphy. Nearly all patients expressed great satisfaction with the telephone follow-up method.

Conclusions  Telehealth can be safely used in selected ambulatory patients as a substitute for the standard postoperative clinic visit with a high degree of patient satisfaction. Time and expense for travel (7-866 miles) were reduced and the freed clinic time was used to schedule new patients.

Delivery of surgical care that is more efficient and cost-effective and has a high degree of patient satisfaction with excellent outcomes is a necessary evolution of the current surgical practice model. An in-person postoperative clinic evaluation is the “gold standard” throughout the United States. Some practices such as Kaiser Permanente use allied health care providers in lieu of surgeons to see the postoperative patients (N. Baril, MD, oral communication, December 12, 2012). The Veterans Health Care System provides care to eligible patients who come from sizeable catchment areas. The patients often must travel significant distances, which represent an investment on their part of time, missed work, and travel costs for a postoperative clinic visit that is typically quite brief. Therefore, as a quality initiative, we examined whether an allied health professional telephone visit could safely substitute for an in-person clinic visit.

For this pilot study, we defined a telehealth visit as a telephone call performed by a trained allied health care provider. This alternative has not been extensively studied, but a review of the literature demonstrates good patient satisfaction without compromise of overall patient care.1– 4 Several studies have shown that patients appreciate the ability to speak with their physicians or a physician’s surrogate by telephone and are highly satisfied with this mode of communication.1– 4 Advantages of telephone contact are the omission of clinic wait times and the elimination of the costs associated with traveling for an in-person clinic visit.2 Studies using telephone follow-up have been conducted in acute and chronic medical and surgical settings,4outpatient anorectal surgery,5 outpatient laparoscopic cholecystectomy,6 and pediatric adenotonsillectomy.7 These reports demonstrate that telephone encounters are safe for the patient and give the opportunity to provide advice and education and selectively identify individuals in need of actual in-person postoperative visits.2,4,8

Elective open hernia repairs and laparoscopic cholecystectomies are ambulatory procedures where potential complications are well characterized and infrequent.9– 10 The majority of postoperative clinic visits are often perfunctory with patients not having substantive issues that need acute medical attention. When there are complications, many of these patients present outside of the clinic visit with either a telephone call to the surgeon or to the emergency department. Therefore, these patients seemed to be the ideal cases that could be used for a pilot study before expanding to other ambulatory cases such as laparoscopic hernia repairs. Advantages to the patient would be convenience, no need to travel, and no loss of time. Advantages to the surgical service would be increased clinic access slots for new patients and decreased cost in the delivery of care.


Telehealth follow-up has been investigated and reviewed in various medical settings.1– 5,7– 8 Despite its demonstrated efficacy, there has not been widespread adoption in surgical practices. Our pilot study successfully demonstrates that patients who underwent elective open herniorrhaphy and laparoscopic cholecystectomy can be followed up safely by telehealth. Moreover, this approach has demonstrated acceptable complication assessment rates. Complications will occur after surgical procedures but the critical question to ask is whether there were any delays in diagnosis or worsened outcomes because of the lack of an in-person clinic visit. All but 1 of the hernia complications within 30 days were minor wound issues; the single serious complication of hematoma presented acutely and represented to the emergency department a second and third time even while being closely followed up in the clinic. No missed morbidity or mortalities were found on 30-day medical record review.

This pilot project was received very positively by our surgical staff and convincingly demonstrated to them that the vast majority of selected ambulatory patient follow-up could be done by telephone, with referral to the clinic based on the telephone evaluation. In the pilot, we learned that a process was necessary to facilitate completion of return-to-work or disability forms outside of a clinic visit. Our hospital is trying to expand the role of telehealth in the care of patients in our large catchment area. The director of the hospital telehealth program now recommends that a formal telehealth appointment be scheduled to set patients’ expectations. The 110 clinic slots that were opened up by use of this program were able to be used for new patients and helped improve clinic access and wait-time issues. We cannot provide any hospital cost data but a 10-minute physician assistant telephone call compared with a 5- to 10-minute surgeon visit in the clinic would most likely show a cost savings. More important is the savings of the patient’s time and resources to drive to the hospital for a brief and often cursory visit. In the cohort that accepted the telehealth visit, 51% had a round-trip driving distance of greater than 100 miles and 71% had a greater than 1 hour total commute.

Greater than 70% of patients contacted via telehealth willingly accepted this mode of communication for their postoperative care and no complaints were received. The observed low complication rate, none of which were directly tied to the lack of a postoperative clinic visit, helps demonstrate that patient care and outcomes were not compromised. It is our belief that this is applicable to non–veterans hospital practices. In general, people appreciate respecting their time, and elimination of a low-impact clinic visit while still maintaining patient contact through a telephone call should result in overall high patient satisfaction.

A potential weakness is the inference of cost savings to the system because a formal cost analysis was not performed. Since this was a pilot program, we can only infer conclusions about the true impact on health care costs. Overall, patients expressed satisfaction for our telehealth services, saving them from driving long distances and clinic wait times.

In conclusion, this pilot study demonstrated that a scripted telehealth visit by an allied health professional can be safely and effectively used for the postoperative care of open herniorrhaphy and laparoscopic cholecystectomy patients. There were no complications that resulted from the substitution of telehealth for a “gold standard” clinic visit. Expansion of telehealth follow-up to other selected procedures with low morbidities will be expanded within our service. The net results of increased clinic slots for new patients; patient satisfaction with avoiding travel; hospital cost savings by not using clinic space, resources, and staffing; and cost shifting the follow-up care from a physician to an allied health professional should all positively impact the cost of care for both the patient and the hospital. Evolution of care needs to continue with the aim of providing outstanding outcomes, at the lowest cost, and with a high degree of patient satisfaction. This program appears to satisfy all of these goals and is a direction that should be considered by other high-volume ambulatory practices, with care taken to select the correct mix of procedures.


Source: JAMA

Surgery Without Scars.

Report of Transluminal Cholecystectomy in a Human Being



Hypothesis  Natural orifice transluminal endoscopic surgery (NOTES) provides the potential for performance of incisionless operations. This would break the physical barrier between bodily trauma and surgery, representing an epical revolution in surgery. Our group at IRCAD-EITS (Institut de Recherche contre les Cancers de l’Appareil Digestif [Institute of Digestive Cancer Research]–European Institute of TeleSurgery) has been actively involved in the development of NOTES since 2004 with a dedicated project created to develop feasibility and survival studies and new endoscopic technology.

Design  NOTES cholecystectomy in a woman via a transvaginal approach.

Setting  University hospital.

Patient  The patient was a 30-year-old woman with symptomatic cholelithiasis.

Intervention  The procedure was carried out by a multidisciplinary team using a standard double-channel flexible videogastroscope and standard endoscopic instruments. The placement of a 2-mm needle port, mandatory to insufflate carbon dioxide and to monitor the pneumoperitoneum, was helpful for further retraction of the gallbladder. At no stage of the procedure was there need for laparoscopic assistance. All of the principles of cholecystectomy were strictly adhered to.

Results  The postoperative course was uneventful. The patient had no postoperative pain and no scars, and was discharged on the second postoperative day.

Conclusions  Transluminal surgery is feasible and safe. NOTES, a radical shift in the practice and philosophy of interventional treatment, is becoming established and is enormously advantageous to the patient. With its invisible mending and tremendous potential, NOTES might be the next surgical evolution.

The abolishment of pain in surgery is a chimera. It is absurd to go on seeking it. . . . Knife and pain are two words in surgery that must forever be associated in the consciousness of the patient.—Dr Alfred Velpeau, French surgeon (1839)

Change is part of surgery but it is never easy to accept. At the dawn of surgery, excellence was associated with big incisions: “Big scar, big surgeon.” Surgery with no scars was an impossible reverie. Now natural orifice transluminal endoscopic surgery (NOTES) is being performed, and the philosophy of surgery will be dramatically changed. Transluminal surgery has the potential to break the physical barrier between bodily trauma and surgery, representing an epical evolution in surgery.

Laparoscopic gallbladder resection changed the focus of surgery and the mindset of nearly all surgeons. Cholecystectomy seems to be the logical next step in developing the clinical application of NOTES.

In 1882, Langenbuch, as cited by van Gulik,1 successfully removed the gallbladder in a 43-year-old man who had cholelithiasis. His initial report was ignored. Nevertheless, Langenbuch’s open cholecystectomy remained the standard criterion for the treatment of symptomatic cholelithiasis for more than a century. In 1985, Muhe, as cited by Reynolds,2 performed the first laparoscopic cholecystectomy using a modified laparoscope, called the galloscope. In 1986, he presented his technique at the German Surgical Society Congress but was strongly criticized. In 1987, Mouret3performed the first laparoscopic cholecystectomy with an approach that would become the standard technique within 2 years, that is, use of 1 optical trocar and 2 other trocars. The world of general surgery was soon divided into a small group of enthusiastic surgeons convinced of the superiority of laparoscopic over conventional cholecystectomy and a second, large group of surgeons with varying opinions ranging from curiosity to frank condemnation of laparoscopic cholecystectomy.

The controversy was intense but short. In 1992, the National Institutes of Health Consensus Development Conference4 statement on gallstones and laparoscopic cholecystectomy concluded that, compared with open cholecystectomy, laparoscopic cholecystectomy was safe and effective in most patients and should be the treatment of choice. Even if surgeons were reluctant to acknowledge this shift in treatment, patients applauded the new minimally invasive surgery. Whenever it was possible, patients would ask for a surgical procedure that left no outer scarring and resulted in no postoperative pain. Patients, both male and female, independent of age and body shape, dislike scars, not only for cosmetic reasons but because scars indicate they have undergone treatment because of illness. This resulted in NOTES, with its general goal of minimizing the trauma of any interventional process by eliminating the incision through the abdominal wall and using natural orifices. To our knowledge, this is the first report of the use of NOTES to treat cholecystectomy in a human being via transvaginal access, performed at University Hospital in Strasbourg, France.


With the successful performance of the first transluminal cholecystectomy, we witnessed the introduction of NOTES into clinical practice with mixed feelings of excitement and caution. Even if the advantages of NOTES in this first clinical case are apparent, transvaginal cholecystectomy is time consuming and difficult. Will NOTES generate a major paradigm shift in surgical care? We know that laparoscopic surgery is just the beginning of the minimally invasive evolution of surgery. We have come to an even more critical juncture in the history of surgery. With its invisible mending and tremendous potential for improving patient care and well-being, NOTES might represent the next greatest surgical evolution.