Is outpatient laparoscopic cholecystectomy wise?

Abstract

The authors report a prospective analysis of their experience with 506 consecutive laparoscopic cholecystectomies to examine the appropriateness of outpatient or same-day laparoscopic cholecystectomy. Thirty-eight patients experienced at least one postoperative complication. The complication was clinically evident or suspected in only 4 of these 38 patients within 8 h following surgery. Thirty-nine percent and 76% of complications were clinically detected at 24 and 48 h, respectively. Nausea and vomiting occurred among 32% of all patients on the day of operation and extended into the 1st postoperative day in 10%. Compared to predicted values, forced vital capacity was 61 +/- 5% 1 h postoperatively in 32 patients studied. At 6 and 24 h postoperatively, forced vital capacity was 63 +/- 7% and 66% respectively. Postoperative analgesic medication requirement was determined in 220 patients who were provided with a patient-controlled intravenous morphine analgesia machine with no basal rate. Consumption of morphine was highly variable but substantial on the day of operation: 17 +/- 16 mg. Most complications of laparoscopic cholecystectomy, including life-threatening complications, are not apparent by 8 h postoperatively and may not be apparent at 24 h. The potential for delay in the diagnosis and treatment of complications, variable but substantial analgesic requirements, impaired postoperative ventilation, and postoperative gastrointestinal dysfunction argue for the need to use great caution in selecting patients for outpatient laparoscopic cholecystectomy. Criteria are proposed to identify patients who are safest for outpatient laparoscopic cholecystectomy.

Comparison Of Analgesic Effects Of Intraperitoneal Lornoxicam And Ropivacaine Administration In Laparoscopic Cholecystectomy.

“…[5,6] Nonetheless, post-cholecystectomy pain may be moderate or even severe for some patients during the first 24 postoperative hours, and has frequently been treated with nonsteroid anti-inflammatory drugs (NSAIDs) or opioid treatment. [7,8] Local anesthetic infiltration is often used to improve pain relief after laparoscopic cholecystectomy. [5,[9][10][11][12][13] The postoperative analgesic effect of intraperitoneal administration of local anesthesia after laparoscopic gynecologic surgery has proved to be effective and safe but there is lack of consensus regarding the dose, concentration, site, and manner of administration.…”

Day-Case Laparoscopic Cholecystectomy: Is it a Safe and Feasible Procedure?

“…Robinsons et al (10) reported their experience in a public academic institution have achieved outpatient LC in 70% of an unselected patients and they have identified ASA classification, procedural duration and surgery start time as factor associated with failure of outpatient management. Some authors have come to the conclusion that appropriate patients selection lowers failure rate and patients most likely to fulfill the criteria of outpatient LC, who have an anesthetic preoperative classification of ASA grade I or II, with no previous abdominal surgery no history of acute cholecystitis and a procedural duration of shorter than 90 min (11)(12)(13). Our univariate analysis results confirmed that patients with age less than 60 years, ASA class 2 or below, and uncomplicated gallstones and disorders were suitable for outpatient LC.…”

Outpatient laparoscopic cholecystectomy: A new gold standard for cholecystectomy?

“…Several authors have demonstrated the usefulness of local anesthetic instillation (especially bupivacaine) before the laparoscopic incision, thus contributing to the minor component of postoperative pain, the need of lower doses of analgesia, and a more rapid recovery to daily activity versus patients not receiving it or having it administered after the surgical incision (8)(9)(10)(11). Anti-emetic prevention, the utilization of propofol as a rapid anesthetic inductor with minimal undesirable residual effects, and the association during anesthetic induction of NSAIDs (ketorolac) have all permitted a successful ambulatorization of LC (6,13,14), which is according to various series around 55-97% (12)(13)(14)(15). Table V shows series reported along the development of the outpatient approach, including case numbers and ambulatorization percentage (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33).…”

“…This percentage in the analyzed series is around 1-39%, mainly due to postoperative symptoms (vomiting and abdominal pain), the elective conversion to open surgery, and patient insecurity (13). Some authors have come to the conclusion that patients most likely to fulfill the criteria of outpatient LC are those who have an anesthetic preoperative classification of ASA I or II, with no previous abdominal surgery, no history of acute cholecystitis episodes, and a procedure duration shorter than 90 minutes (3,14,16).…”

“…Diverse authors question the safety of ambulatorization arguing the potential for delayed detection, and therefore solution, of postoperative complications that cannot be demonstrated within 24 hours after surgery (14,17). The main reticence regarding the ambulatory approach derives from the fact that many surgeons prefer periods of at least 24 hours with overnight stay, which avoid delays in the detection of some complications in the immediate postoperative period.…”