A microscope can make an operation more intricate. It does not necessarily make the hospital more necessary.
Vanessa Gabrovsky Cuéllar, MD, an orthopedic hand and wrist surgeon and physician partner at DISC Surgery Center at Palm Beach (Fla.), performs delicate nerve repairs, fracture fixation and other complex procedures involving some of the body’s smallest structures. The work can demand extraordinary precision. It may require specialized equipment, advanced anesthesia and a highly trained surgical team.
Increasingly, it does not require an inpatient hospital.
“The discussion about what is safe to do inpatient versus outpatient has a lot more to do with the patient’s medical condition than the type of surgery being done,” Dr. Cuéllar told Becker’s.
That distinction is quietly redrawing the boundaries of orthopedic surgery. For years, the complexity of an operation often determined where it was performed. Smaller procedures went to outpatient centers. Longer, more difficult or technologically involved cases remained in the hospital.
Hand surgery is challenging that hierarchy. Procedures once considered too involved for an ASC are now routinely performed there. Patients previously regarded as too medically fragile for outpatient care may also be eligible after better preoperative optimization and advances in anesthesia.
The movement is not being driven by one implant, robot or breakthrough technique. It is the cumulative result of better pain control, more focused surgical teams, growing clinical experience and a deeper understanding of what actually makes an operation risky.
Hand surgery may soon offer a preview of where much of orthopedics is headed: increasingly complex care delivered in smaller settings, with less anesthesia, less hospital exposure and less disruption to the patient’s life.
Complexity is not the same as risk
Many common hand procedures have long been performed on an outpatient basis. Carpal tunnel release, trigger finger surgery, ganglion cyst removal and treatment of other small masses generally carry low risk compared with more extensive orthopedic operations.
The frontier has shifted to procedures that take longer or require greater technical expertise. Wrist and forearm fractures once viewed as too involved for ambulatory care are now commonly treated outside the hospital. Dr. Cuéllar said even highly specialized nerve repair can be performed in an ASC with a microscope and the appropriate team.
The operation may be complex. The patient may still be able to leave shortly afterward.
“I can do a highly complex, highly involved surgery such as nerve repair,” she said. “That doesn’t necessitate me using any hospital resources.”
The shift exposes a misconception that has influenced site-of-care decisions for decades: that a complicated procedure automatically requires a larger facility. Often, the more consequential factors are the patient’s underlying health, anesthesia requirements and ability to recover safely at home.
A highly technical operation on a medically stable patient may be well suited to an ASC. A relatively straightforward procedure on a patient with poorly controlled chronic disease may not be. The procedure alone no longer tells leaders where the case belongs.
Why the smaller setting can be safer
Hospitals are built to manage nearly every scenario. That breadth is essential for emergencies and medically complex cases. It also creates overhead, competing priorities and operational layers that may have little relevance to a routine orthopedic procedure. A focused ASC is designed differently.
“A properly run ASC is a well-oiled machine,” Dr. Cuéllar said. “It is a highly specialized, superbly focused center that excels at being state of the art while also being extremely efficient.”
Efficiency is often framed as a business advantage. For Dr. Cuéllar, it is also a clinical one.
A specialized team can move through the procedure more quickly. The patient spends less time under anesthesia and less time exposed to a large hospital environment. The staff repeatedly perform similar workflows and become familiar with the surgeon’s instruments, preferences and recovery protocols.
“The quicker I do the surgery, the less time the patient spends under anesthesia and in the center, the better they’re going to do,” she said.
That logic can also extend outpatient eligibility to patients who might once have been considered too medically fragile. A shorter operation with a focused team may reduce some of the risks associated with prolonged anesthesia and hospitalization. The ASC does not eliminate the patient’s diabetes, hypertension or other chronic conditions, but better preoperative management can bring those conditions under control before surgery.
The outpatient expansion is therefore not only a story about moving procedures. It is a story about preparing patients well enough that the hospital becomes unnecessary.
Pain control changed the equation
One of the most important advances has occurred outside the incision. Local anesthetics and regional nerve blocks can provide substantial pain relief while reducing or eliminating the need for general anesthesia. They can also control postoperative discomfort well enough for patients to return home rather than remain overnight.
“One of the biggest reasons people stay overnight after an otherwise outpatient surgery is for pain control,” Dr. Cuéllar said. Hand and wrist procedures are especially suited to regional approaches because anesthesiologists can target the nerves supplying the operative area while limiting the systemic effects of deeper anesthesia.
That can shorten recovery, reduce nausea and allow surgery in patients who may face elevated risk under general anesthesia. Dr. Cuéllar believes nearly every hand surgery patient should be able to return home comfortably after the procedure when the right perioperative team and pain plan are in place.
The hospital stay is not being shortened through optimism. It is being engineered out of the episode.
Some of the progress came from confidence
Not every case moved outpatient because the operation itself changed. In some instances, surgeons are performing largely the same procedure, with familiar instruments and similar anesthesia, in a different environment.
What changed was the evidence. “There was fear associated with ‘what if,’” Dr. Cuéllar said. “No one wants to be the one to go out on a limb.”
Pioneering surgeons and researchers began demonstrating that procedures traditionally confined to hospitals could be performed safely in ambulatory settings. As the outcomes accumulated, other physicians became more comfortable moving their own cases.
Innovation was not always a new technique. Sometimes, it was the removal of an old assumption.
“That proof has encouraged surgeons who may not be changing their techniques much,” she said. “It may just be the confidence that, yes, it is OK and safe to move these cases.”
Once the threshold shifts, it can be difficult to justify returning to the larger setting. As Dr. Cuéllar put it: “It’s hard to go back once you cross that line.”
The real art is deciding not to operate
Orthopedic innovation is often described through addition. A new implant enters the market. A robot joins the operating room. A more elaborate procedure becomes technically possible. Dr. Cuéllar believes surgical maturity often moves in the opposite direction.
“With experience and wisdom comes a refinement where you realize less is more,” she said. “I’ve noticed even in my own practice, you become more and more cautious and less and less aggressive.”
The ability to perform a complex operation does not make the operation appropriate. During training, she heard a blunt expression: Almost anyone can be taught to operate. The art of surgery lies in knowing when to do it.
That judgment depends on more than the diagnosis. The surgeon must understand the patient’s goals, occupation, activity level, tolerance for recovery and expectations. The most technically impressive procedure may not be the one that provides the most value.
“What really matters at the end of the day is: Do you understand your patient?” she said. “Are you making the right decision about when to operate, not just how?”
That philosophy fits naturally with outpatient care. An ASC rewards focus and efficiency, but it should not become a reason to expand indications or move every possible case into surgery. The best ambulatory program is not the one that performs the most procedures. It is the one that identifies which patients truly benefit and delivers that care with the least disruption possible.
When the neck and hand tell the same story
Dr. Cuéllar’s position at DISC Palm Beach places a hand and wrist surgeon inside an organization primarily known for spine care.
At first, the specialties may appear distinct. In practice, their patients frequently overlap. A patient with cervical nerve compression can also have carpal tunnel syndrome. Symptoms in the hand may originate in the wrist, the elbow, the neck or more than one location at once.
Treating each condition in isolation can fragment the patient’s care. Dr. Cuéllar sees value in having spine and peripheral nerve specialists working within the same surgical environment. Physicians can compare findings, determine which condition is driving the symptoms and, in selected cases, coordinate procedures rather than making the patient undergo separate episodes months apart.
“So many spine patients have concurrent hand issues, or vice versa,” she said. “It allows different specialists to interact and weigh in rather than having the care spread out with no communication.”
The arrangement reflects another evolution in ambulatory surgery. The ASC is no longer only a lower-cost room where individual surgeons perform isolated procedures. It can become a clinical platform where specialties intersect around the patient.
That matters as healthcare moves toward greater accountability for outcomes across the entire episode. A technically successful hand operation may not solve the patient’s problem if cervical pathology was also contributing to the symptoms. The smallest setting can still require the broadest view.
Patients are no longer accepting decline as inevitable
The growth of outpatient hand surgery is also being driven from outside the medical system. Patients are living longer and remaining active later in life. They are less willing to regard pain, stiffness or loss of function as unavoidable consequences of aging.
In Palm Beach, Dr. Cuéllar sees patients who want to return to golf, tennis, exercise and other activities. They may arrive with a diagnosis in mind, a procedure they have researched and a preference for where they want it performed.
“They come in with their diagnosis,” she said. “They’ve had a consultation or two with Doctor Google already.”
The information is not always correct. Patients may misinterpret symptoms, become fixated on a procedure or assume they have the same condition as a relative. Dr. Cuéllar often has to redirect or reeducate them.
Still, she views greater patient engagement as a positive development. People are more interested in understanding their condition, seeking second opinions and finding treatment that preserves their quality of life. They are shopping for care in ways previous generations rarely did.
The care model must respond. Minimizing anesthesia, hospital exposure, postoperative pain and recovery time is no longer merely an operational goal. It is part of what patients expect when selecting a surgeon and facility. They do not simply want the condition treated. They want their lives interrupted as little as possible.
Hand surgery’s next frontier remains wide open
Hand surgery has already moved heavily into the outpatient setting. Dr. Cuéllar believes the next five years may produce even more dramatic changes in what surgeons do there.
Unlike hip and knee replacement, where modern implants and techniques are comparatively mature, several areas of hand surgery remain unsettled. Hand and wrist arthroplasty has not reached the same level of predictability or widespread adoption as large-joint replacement. Treatments for Dupuytren contracture continue to evolve. Minimally invasive techniques for carpal tunnel and finger procedures remain ripe for refinement.
Innovation may also come from materials: new suture biology, improved plates and screws and technologies that support healing rather than merely hold tissue in place.
“Hand surgery is such a wide-open field with so many areas that are still ready for completely new concepts,” Dr. Cuéllar said. New procedures will require evidence, training and time before they become routine. But she expects most of them to be developed with ambulatory care in mind.
Acute trauma, complex tumors and reconstructions requiring multiple specialties will continue to need hospital resources. Outside those exceptions, Dr. Cuéllar believes very little hand and wrist surgery may remain in the hospital over time.
The shift will not happen because the work becomes less sophisticated. It will happen because the systems surrounding that work become more sophisticated.
Smaller setting, larger standard
The movement of hand surgery into ASCs is sometimes reduced to a cost story. The outpatient setting does lower overhead and can reduce spending compared with hospital care.
But cost alone does not explain why surgeons and patients rarely want to move back. A focused facility can offer shorter procedures, specialized teams, less anesthesia, lower exposure to hospital-associated risks and a recovery plan built around returning home. Those advantages become more meaningful as procedures grow more complex and patients remain active later in life.
The hospital will not disappear from hand surgery. Its role may become narrower and more intentional, reserved for the patients and conditions that genuinely require its resources.
That is a more consequential transformation than simply moving cases from one building to another. It changes the standard by which surgical care is judged. The question is no longer whether a complicated operation can be performed in an ASC. It is whether the patient needs everything the hospital adds around it. In hand surgery, the answer is increasingly no.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.