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Day Care Laparoscopic Cholecystectomy: The Indian Experience

This study examines the feasibility and outcomes of day care laparoscopic cholecystectomy (LC) in the Indian setting. The study assesses patient selection criteria, anesthesia protocol, discharge criteria, and morbidity and mortality rates. The results demonstrate that day care LC is feasible and can be performed safely with minimal morbidity and no mortality.

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Day Care Laparoscopic Cholecystectomy: The Indian Experience

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  1. Day Care Laparoscopic Cholecystectomy-The Indian Experience Kaman L, Iqbal J, Singh R Dept of General Surgery PGIMER, CHANDIGARH-160012 INDIA

  2. INTRODUCTION • Laparoscopic cholecystectomy - the gold standard • Shortened hospital stay, less post operative pain and side effects • Laparoscopic cholecystectomy is still done as inpatient basis • Day care LC has been adopted by many centers in the West • Indian scene is not very clear

  3. AIMS AND OBJECTIVES • Reviewed the initial experience at PGIMER, Chandigarh, India • Aimed to determine - appropriate patient selection criteria - anesthetic protocol - discharge protocol - morbidity and mortality

  4. PATIENTS AND METHODS • Between Nov 2004 to Dec 2009 • Patients of symptomatic gall stones, suitable for surgery under GA • Operated by the two participating surgeons • 309(51%) out of total 602 LC

  5. INCLUSION CRITERIA • Elective cases only • ASA Grade I and II • Less than 70 years and above 18years • Not using warfarin • BMI <35 kg/m2 • Unlikely to have CBD stones • Willing for day care LC • Adequate home supports • Access to telephone • Lives within 30 minutes of medical care

  6. SURGICAL AND ANESTHESIA PROTOCOL • Assessed by surgical team for suitability for day care LC • Explanation of the protocol and intention • Written consent for the procedure • Emphasize on the suitable escort • Pre anesthesia check up in the OPD • Visit the preoperative room

  7. SURGICAL AND ANESTHESIA PROTOCOL • Scheduled - early in the morning list • Tab diazepam 10mg and Tab ranitidine hydrochloride 150mg along with Tab metochloropropamide 10mg at 2200 hours night before the surgery • 06.00 hours Tab diazepam 5mg and Tab ranitidine hydrochloride 150mg along with Tab metochloropropamide 10mg as premedication.

  8. SURGICAL AND ANESTHESIA PROTOCOL • Surgery under GA with ET intubation • Induction with fentanyl 2mg/kg, propofol 2mg/kg and vancuronium 0.1mg/kg • Trocar site infiltration prior to incision

  9. SURGICAL AND ANESTHESIA PROTOCOL • LC was done using 4 port technique • Operative area and Subphrenic space lavage with 500ml of NS • Port sites were infiltrated with 0.5% bupivicaine • Patients shifted to recovery room

  10. DISCHARGE CRITERIA • Vitals signs must be within 20% of the preoperative level • Able to ambulate and understand instructions • Pain and nausea/vomiting relieved • No bleeding from surgical sites • Able to void and tolerate oral fluids

  11. DISCHARGE CRITERIA • Four factors were specifically evaluated: nausea, vomiting, incisional pain and shoulder tip pain • Provided with drugs (tab diclofenac 50mg thrice and tab ondansetron 4 mg twice daily ) • Phone numbers – residents/surgeons • Report to the emergency if needed

  12. ADMISSION CRITERIA • Conversion to open cholecystectomy • CBD stone found at operation • Bleeding from wound sites • Prolonged surgery (> 4 hours) • Unstable vitals signs • Pain,nausea/vomitting inadequately controlled • Unable to tolerate oral fluids and void urine

  13. RESULTS • 309 (51.32%) patients were found suitable for DCLC out of total 602 LC • 219(75%) patients excluded for living out of defined area • 270(87%) females and 39(13%) males • Median age 42 years (18-70 years) • 230(74%) in ASA I and 79(26%) in ASA II

  14. RESULTS • Indications for surgery • recurrent biliary colic in 217(70%) • previous episodes of acute cholecystitis in 92(30%) • Median operating time was 44 minutes(33-190)

  15. Failure to Discharge • Thirteen Patients (4.2%) • Nine patients were converted to open - 5 for distorted calot’s triangle anatomy - 2 for CBD stones - 1 for bleeding from cystic artery - 1 for MBDI • One patient had MI • Three patients had refractory PONV • 296 patients (96%) were successfully discharged on the same day

  16. Post Operative Pain (n=296) Assessment at the time of Discharge (6-8 hours after surgery) • Incisional pain • Mild ----------- 61 (19.8%) • Moderate -------–--- 240 (77.6%) • Severe ----------- 8 (2.6%) • Shoulder tip pain • Nil –----------- 154 (49.8%) • Mild –----------- 140 (45.3%) • Moderate –---------- 15 (4.9%) • Severe –---------- 0 (0%) Mild – no medication Moderate – oral medication Severe – IV/IM medication

  17. Post operative Nausea and vomiting (n=296) At discharge Next day Nausea Mild 41(13.85%) 4 Moderate 78 (26.54%) 2 Severe 4 (1.2%) 0 Vomiting Mild 34(11.48%) 3 Moderate 17(5.74%) 3 Severe 1 (.4%) 0 Mild – no medication Moderate – oral medication Severe – IV/IM medication

  18. Readmissions • Three patients readmitted • Two with abdominal collection – Pigtail catheter drainage • One with Fever • None required surgery • No mortality

  19. CONCLUSION • Day care LC is feasible (96%) • Careful patient selection is needed • Detailed explanation and education • Appropriate admission and discharge criteria • Procedure can be done safely with minimum of morbidity and no mortality

  20. Thank You

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