Original                 Article

                       A FEASIBLE OPTION

Department of Surgery, Hamdard College of Medicine & Dentistry, Karachi
Department of Surgery, Ziauddin Medical University, Karachi*

Objective: To evaluate the feasibility & outcome of Day care Laparoscopic Cholecystectomy in an independent
daycare unit.
Design: Case series.
Setting & Duration: Advanced Surgical & Medical Clinic (a private day care unit) in Karachi from August 2001
to January 2005.
Methodology: Patients who presented with diagosis of cholelitiahisis and consented to day care laparoscopic
cholecystectomy were included. Selection criteria included age <60 years, ASA grade I & II, no signs & symptoms
of acute cholecystitis, normal liver function tests, weight <100 kg and adequate support. Duration of surgery,
complications, conversion, patients requiring overnight stay and factors responsible were analyzed.
Results: Day care Laparoscopic Cholecystectomy was attempted in 113 patients out of which 100(88.5%) were
female & 13(11.5%) male with mean age of 37.9 yrs. 99(87.61%)patients were discharged on the same day whereas
14(12.39%) stayed overnight, there were no readmissions. Causes of overnight stay included excessive post operative
nausea & vomiting in 5(4.43%), drain placement in 4(3.54%), conversion to open in 3(2.65%) & patient preference
in 2(1.77%). Complications included port site infection in 5(4.43%), port site hernia in 1(0.88%) & minor biliary
leakage in 1(0.88%).
Conclusion: Day care Laparoscopic Cholecystectomy is a feasible and safe option in selected group of patients in
an independent day care surgical unit

KEY WORDS: Day Care Surgery, Ambulatory Surgery, Laparoscopic Cholecystectomy, Outpatient Surgery

 INTRODUCTION                                                     series supporting this as a safe and cost effective proce-
                                                                  dure. Since then laparoscopic cholecystectomy in day
Laparoscopic cholecystectomy has become the gold                  care setting has been widely studied as supported by
standard for treatment of symptomatic gallstone disease           studies by Mjaland5 and other authors as well.6,7
because of faster recovery, less postoperative pain,
earlier return to work and better cosmesis.1                      Many studies have demonstrated the safety, feasibility
                                                                  & cost effectiveness of Day care Laparoscopic Cholecys-
The potential of performing laparoscopic cholecystec-             tectomy and in a meta analysis of five randomized con-
tomy as day care surgery was recognized early when                trolled trials. Gurusamy concluded that Day care Lapa-
a trial published in New England Journal of Medicine              roscopic cholecystectomy is a safe and effective treat-
in 1991 demonstrated length of stay as short as 6 hours.2         ment for symptomatic gallstones.8 It has become well
Fleming3 and Prasad4 presented their findings in their            established in selected patients in many centres of the
                                                                  developed world but information is limited from dev-
                                                                  eloping nations,9-14 however Kaman15 and Chauhan16
                                                                  from India have also reported it to be safe, feasible,
Correspondence:                                                   acceptable to patients and with social and economic
Dr. Muhammad Zubair                                               benefits.
Assistant Professor of Surgery,
Hamdard College of Medicine & Dentistry, Karachi.                  METHODOLOGY
Phones: 0321-9282015.
E-mail:                                     This study was conducted at Advanced Surgical &

                                                            182                          Volume 24, Issue 3, 2008
 Day Care Laparoscopic Cholecystectomy                                                                        M. Zubair, M. J. Dinar

Medical Clinic (an independent day care unit with                   of epigastric and two of umbilical ports. One patient
facility of overnight stay if required) in Karachi over             developed umbilical port site hernia seven months after
a three and a half year period from August 2001 to                  surgery.
January 2005. All patients who fulfilled the selection
criteria were counseled & booked for Day Care Laparos-               DISCUSSION
copic Cholecystectomy. Selection criteria were age less
than sixty years, American Society of Anesthesiologists             Our results demonstrate that day care laparoscopic
grade I & II, no signs & symptoms of acute cholecystitis,           cholecystectomy is a safe and feasible option, as shown
normal liver function tests, weight less than hundred               by Fleming3 in 2000, Siu10 from Hong Kong, Keule-
kilogram and adequate support which meant availability              mans14 and Kaman.15 In day care surgery, patient selec-
of a responsible adult to care at home, access to telephone         tion criteria have an impact on success rates, 87.61%
and ability to come to hospital if needed.                          discharge rate and no readmissions indicate that the
                                                                    selection criteria were appropriate even though day care
The perioperative and anaesthetic regimens were                     laparoscopic cholecystectomy has been demonstrated
standardized. Patients were admitted at 7.30a.m. and                to be safe in older and high risk (ASA grade III) pati-
operated at 8.00a.m., mobilized around 2.00p.m. and                 ents.17 Discharge rates in the published literature vary
discharged between 6.00 & 8.00p.m. after being                      greatly from 55 to 100%.18 It is felt that with increasing
reviewed by the surgeon. 1.5 gm Cefuroxime was used                 experience a wider range of patients can be submitted
for prophylaxis and Diclofenac 100mg suppository and                to day care laparoscopic cholecystectomy.
pot site infiltration of Bupivacaine was used in all
patients. A single dose of Inj. Diclofenac Sodium was               The mean age of 37.9 years in this study is less as com-
administered 6 hours after surgery. Telephone numbers               pared to other local studies because of selecting patients
of the surgeon & manager were given to the patient for              less than 60 yrs and only ASA grade I & II whereas the
contact if required.                                                sex distribution matches well with Saeed19 and Khan.20
                                                                    The mean operative time of 43 mins is also in accordance
 RESULTS                                                            with that mentioned by Khan20 from Karachi in 2007,
                                                                    Jain21 in 2005 and Lau.22 It has been reported that length
A total of 113 patients were booked for Day Care Lapa-              of operation is an independent predictive factor for un-
roscopic Cholecystectomy (DCLC), out of which 100                   anticipated admission and on operative time exceeding
(88.5%) were female & 13(11.5%) male with mean age                  60 minutes incurred a 4-fold increased risk.23
of 37.9 years (range 16 to 59 yrs). The mean operative
time was 43 minutes ranging from 25 to 90 minutes.                  The reasons for overnight admission that have been
                                                                    reported include nausea & vomiting, pain, conversion,
Out of these 113 patients ninety nine (87.61%) were                 patient preference, drain placement and retention.23
discharged on the same day whereas fourteen (12.39%)                Complications and reason for conversion are same whe-
had to stay overnight, however during this study there              ther Laparoscopic cholecystectomy is performed in
were no readmissions. Causes of overnight stay included             daycare or admission setting but excluding obese patients
excessive post operative nausea & vomiting in five                  and those with acute cholecystitis reduces the incidence
(4.43%), drain placement in four (3.54%), conversion                in day care surgery.
to open cholecystectomy in three (2.65%) & patient
preference in two (1.77%) Table I. Complications                     CONCLUSION
occurred in seven out of the 113 patients operated. One
patient had minor biliary leakage which settled in three            Day care Laparoscopic Cholecystectomy is a feasible
days, five (4.43%) patients had port site infection, three          and safe option in selected group of patients in an
                                                                    independent day care surgical unit
       Table I. Reasons for overnight stay

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  Day Care Laparoscopic Cholecystectomy                                                                     M. Zubair, M. J. Dinar

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                                                 EDITORS NOTE
                                This Article was submitted by corresponding author
                                     after the demise of Dr. Junaid Dinarwala

                                                            184                          Volume 24, Issue 3, 2008

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