Day by day, surgery gets easier

Medicine's healing repertoire has never been greater. In his second article on changes in Auckland hospitals, health reporter MARTIN JOHNSTON looks at improving treatments.

The Americans call it office surgery. Here, it goes by the unattractive title "ambulatory care."

It doesn't have a lot to do with ambulances. But it is revolutionising surgery for many - from those with dodgy gall bladders to people needing minor bone surgery.

"Day surgery" is its more user-friendly title - because its recipients can usually come into the clinic (or doctor's office in the United States), have their surgery and go home, all in one day.

The Auckland District Health Board has latched on to this international trend in its $423 million, five-year hospital demolition and reconstruction blitz.

The board now provides the whole spectrum - literally dozens-of services, from outpatient assessment clinics to long inpatient stays for complex surgery, at all of its four main hospitals, Auckland, Starship, Green Lane and National Women's.

But under the rebuilding plan, all higher-level or "acute" services, including treatment of accident and emergency victims, will be provided at a new, 710-bed hospital at the Grafton Rd site. For children, the service will be at the adjacent Starship hospital.

National Women's will be demolished. A refurbished Green Lane, with a new building beside it, will become the country's biggest centre for day surgery, outpatient clinics and rehabilitation services.

Have some services already shifted to Green Lane?


Yes. They include audiology, dermatology, dental, some kidney dialysis, and some day surgery.

Completion of the new hospital at Grafton - the piles are now being sunk - is more than two years away, so much of the switch-around will not happen until after then.

What other services will be at Green Lane?


It is a long list. A sample includes minor orthopaedics (bone surgery), some neurology assessment, and ear-nose-and-throat services (such as grommets in children's ears).

There will also be surgical pre-assessment clinics, some endoscopy (such as checks for a stomach ulcer with a video-camera-equipped tube down the throat), lung outpatients, and heart patients (assessment and outpatients). And some gynaecology, diabetes services, ophthalmology, urology, and sexual health services.

In future, it is hoped that even mastectomies may be able to be performed there. This is on the horizon for day or short-stay surgery. It is done in the United States, but not yet in New Zealand.

Will the shift enable any improvements in services?


Yes. Some examples:

Hernia repairs, gall-bladder removals.

These are now performed through tiny incisions with laparoscopes, narrow tubes fitted with video cameras and remote-control surgical instruments. They are the two most common general surgical procedures at Auckland Hospital.

They will commonly be performed as day-stay operations at the new Green Lane centre.

This means more patients will be able to be treated, helping Auckland Hospital to address its waiting list problem, says a surgeon, Associate Professor John Windsor.

"I've got some people who have waited three years," says Mr Windsor, adding that the hospital has had to subcontract some of this work out to private surgeons.

The move to Green Lane will coincide with the public sector's increasing use of laparoscopy for hernia repair, "which is associated with more rapid recovery."

Eye surgery.

Eye surgery is also expected to get a boost from the shift, partly because the ophthalmology department will be able to use a third operating theatre and will have more efficiently laid-out facilities.

Auckland Hospital head of opthalmology Professor Charles McGhee expects this to lead to an increase in the number of operations to remove eye cataracts.

Cataract removal is the most common operation for people aged over 65 in New Zealand.

Almost 90 per cent of cataract operations at the hospital use the "phaco, no-stitch foldable lens" technique. It uses ultrasound and requires an incision only 3mm to 4mm long in the eye for the new lens to replace the old one, which becomes opaque with cataract.

Professor McGhee expects that, after the shift, this operation will be used on up to 98 per cent of cataract patients.

Gynaecology patients

This will be another group to benefit from the shift to Green Lane - in their case a fairly short move from National Women's.

More women are expected to have day-stay surgery at the Green Lane centre, although the more complex and serious cases will go to the new hospital at Grafton.

The National Women's clinical head, Dr Rob Buist, says the use of minimally-invasive surgery and drug-based treatments for women with problems in their reproductive organs is increasing.

That means fewer major operations and shorter hospital stays.

Ovarian cysts, incontinence, hysterectomy

Dr Buist says removal of ovarian cysts required a "decent-sized cut" only five years ago. But it can now be performed using a laparoscope or "keyhole surgery."

An operation to treat incontinence, which once required a five-day hospital stay, can now be done as day-stay surgery under local anaesthetic.

And some women who suffer heavy periods can have hormone-releasing contraceptive devices put into the uterus to avoid the need for a hysterectomy.

What are some of the high-level services that the new hospital will provide?


It will continue with all the services provided by the Auckland health board's hospitals now and not available anywhere else in New Zealand.

These include liver, heart and lung transplants, children's heart surgery, and some neonatal intensive-care services.

Liver transplants using a piece of the liver from a live donor are being considered.

Liver transplants in New Zealand so far have only used livers from people who have died.

The director of the New Zealand Liver Transplant Unit, Professor Stephen Munn, says Auckland Hospital surgeons have performed a number of combined organ transplants, such as heart-liver and heart-kidney, and a liver and lung transplant is being contemplated.

This would be the first operation of its kind in New Zealand or Australia.

Mr Windsor says Auckland Hospital has led many new developments in laparoscopic surgery in New Zealand.

A recent development is "hand-assisted laparoscopy," in which a large incision is made, for example in live-donor kidney transplants to remove the organ from the donor.

One of the advantages of using laparoscopy in a kidney transplant is that the incision can be made lower in the donor's abdomen, which is more comfortable for the patient.

With less time spent in hospital for the donor, laparoscopic kidney transplants may become more attractive to donors, Mr Windsor says.

What range of services does the hospital provide?


Another huge list. Public hospitals throughout New Zealand provide secondary services covering virtually all areas of sickness and accident trauma at a general-hospital level, while a handful in main centres also provide the next level up, tertiary services, for the more complex, serious cases.

The Waitemata District Health Board provides secondary services at North Shore Hospital.

Some of these are cardiology, asthma treatment, dermatology, diabetes services, gastroenterology, medical oncology, neurology, renal medicine, urology, plastic surgery, and gynaecology.

The central Auckland hospitals have a wide range of tertiary services and are the main providers of national services.

Middlemore's tertiary services include some orthopaedic cases and some paediatric plastic surgery. It also takes seriously burned patients from all over the country.

At which hospitals can women have babies delivered?


In central Auckland, women will be able to go to National Women's until October 2003, when the delivery service will shift to the new hospital at Grafton.

After the shift, some ante-natal outpatient clinics will be held at Green Lane. Others will continue at a variety of sites around the city.

The privately-owned Birthcare Auckland maternity hospital in Parnell also provides, through a contract with the Government, taxpayer-funded deliveries and post-natal stays. For their post-natal stays, women can opt to pay a top-up charge of $200 a night for better rooms and a menu with a wider choice of food.

Birthcare, which opened its new premises in Parnell yesterday, has four birthing suites, 20 beds in 10 rooms for public patients and 21 single rooms for the $200-a-night women. Its Government contract is for up to 1000 births a year and up to 3000 post-natal stays.

Since it is authorised to cater only for uncomplicated births, women cannot have epidural pain relief or caesarean section deliveries. Its focus is on natural births, for which managing director Lee Mathias says there is a growing demand. With this in mind, a pool was installed in one of the birthing suites for water births.

The other maternity units in the region are at Middlemore Hospital, North Shore Hospital, Waitakere Hospital, the Botany Downs, Papakura and Pukekohe Obstetric Units, and the Warkworth and Helensville Birthing Units.