Outcome and patient acceptance of outpatient laparoscopic cholecystectomy.

OBJECTIVE: The aim of this prospective study was to evaluate patients' experience and the outcome of outpatient laparoscopic cholecystectomy performed by a single upper gastrointestinal surgeon at a district hospital.
METHODS: Between November 1999 and May 2003, 100 patients underwent outpatient laparoscopic cholecystectomy. Patients were followed up at 2 weeks as outpatients, and a questionnaire was mailed to all patients to assess their experiences.
RESULTS: None of the patients required conversion to open cholecystectomy. One patient required admission to the hospital following drain insertion, and one patient was readmitted for pain control. One patient developed an epigastric port infection that resolved with antibiotics. Sixty-eight of the 100 patients completed the postal questionnaire. Thirty-five patients rated their overall experience as excellent. Twenty-three patients experienced very mild or no pain. All patients' right upper quadrant pain subsided or improved following surgery except one patient who stated that it became worse. Sixty-three patients (92.7%) stated they would recommend outpatient laparoscopic cholecystectomy to a friend or relative.
CONCLUSION: Laparoscopic cholecystectomy can be performed safely as an outpatient procedure with a high acceptance and satisfaction rate in select patients.

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the operation of choice for symptomatic gallstones, and it was performed for the first time on an outpatient basis in 1990.[1] Several reports[2-4] have demonstrated the feasibility, safety, and cost-effectiveness of this operation as an outpatient procedure. However, outpatient LC has been questioned because of difficult to control postoperative pain and nausea[5] and because of the possibility of a higher morbidity rate.[6, 7] It is for these reasons that outpatient LC is not the current practice in the United Kingdom.

The objective of this prospective study was to assess patients' experience and morbidity as well as unplanned admission and readmission rates following ambulatory LC at a London district hospital.

METHODS

From November 1999 to May 2003, 100 well-motivated patients (9 males; 91 females; age range 18-69 years; mean age 44 years) with symptomatic cholelithiasis and an American Society of Anesthesiologists (ASA) Grade I or II underwent outpatient LC.

Patients with acute cholecystitis, abnormal liver-function tests, ASA>II, and patients not fitting the general surgical outpatient criteria (morbidly obese patients, patients older than 70 years, or any patient living alone) were excluded from our study. The selection criteria were applied once the diagnosis of cholelithiasis was established. All patients who did not fit these criteria underwent LC as inpatients.

All operations were performed in the morning at our day surgical unit by a single upper gastrointestinal consultant surgeon with an interest in laparoscopic surgery in the presence of a consultant anesthesiologist. A Veress needle was used to induce pneumoperitoneum prior to performing a conventional 4-port LC with local anesthetic (10 mL of 0.5% bupivacaine) infiltration of the skin incisions.

All patients received a standardized anesthetic and were premedicated with 1 g acetaminophen and 400 mg ibuprofen one hour preoperatively. Tramadol (50 mg) was used in case of a contraindication for acetaminophen or ibuprofen. Induction of anesthesia was achieved with propofol (2 mg/kg), fentanyl (1 mg/kg), and atracurium (0.3 mg/kg). Each patient received 50 mg cyclizine and 4 mg ondansetron as preemptive antiemetics. Anesthesia and analgesia were maintained by propofol and remifentanil as a target controlled infusion. At the conclusion of the operation, all patients in our series had adequate muscle function, and therefore we did not utilize reversal agents.

Patients were discharged on the same day following assessment by the operating surgeon with a contact telephone number and were followed up at 2 weeks as outpatients. The postoperative pain control regime consisted of 1 g of acetaminophen 4 times a day together with 400 mg of ibuprofen 3 times a day as a regular prescription for the first 3 days and then on an as required basis. Tramadol 50 mg 4 times was used if there was a contraindication for any of the above 2 drugs.

A questionnaire was mailed to all patients to assess overall experience, postoperative pain, improvement of pain, whether they would recommend the procedure to a relative or friend, and whether they would have preferred staying in the hospital overnight.

RESULTS

There was no hospital mortality, and none of the patients required conversion to open cholecystectomy. The mean length of the operation was 38±9.2 (SD) minutes. Of the 100 patients, only one required an overnight stay in the hospital following insertion of a drain that was removed the next day. One patient was readmitted to the hospital for 2 days for pain control. One patient developed an epigastric port infection that resolved with antibiotics.

Sixty-eight of the 100 patients completed the postal questionnaire. Thirty-five patients rated their overall experience as excellent (29 very good, 3 good, and 1 poor). Seven patients experienced no pain after the operation (16 very mild, 8 mild, 23 moderate, and 14 severe pain). All patients' right upper quadrant pain subsided or improved following surgery except for one patient who stated that it became worse. Sixty-three patients (92.7%) stated they would recommend outpatient LC to a friend or relative, and 14 patients (20.5%) would have preferred staying in the hospital overnight.

DISCUSSION

The present study demonstrates that our hospital admission rate compares favorably to that of other reported series that ranged between 1% and 39%.[2,3,8-12] Postoperative nausea and vomiting was the most common reason for overnight stays in the above series, but this did not appear to be a problem in our study. The length of operation has been shown to be another independent predictor for unplanned admissions.[13, 14] The mean length of LC in our series appears to be less than that in other series because an experienced laparoscopic surgeon performed all operations and because no concomitant procedures such as intraoperative cholangiograms were required. A preemptive antiemetic regime with cyclizine and ondansetron together with a short operation might explain our low incidence of postoperative nausea and vomiting.

Readmission rates after ambulatory LC range between 2% and 8%,[4,9,11] and retained stones is the commonest morbidity after LC.[15,16] Only one patient in our series was readmitted for pain control, and one patient was treated with antibiotics as an outpatient for a wound infection. Fourteen of the 68 (20.5%) patients would have preferred spending the night in the hospital, which may, in part, be attributable to patient's concerns about participating in a study that involves leaving the hospital on the same day, which is not actually the current practice.

CONCLUSION

Our experience with ambulatory LC demonstrates that this procedure can be performed safely with low morbidity and with a high satisfaction and acceptance rate in well-motivated select patients when operated upon by an experienced laparoscopic surgeon in the presence of an experienced consultant anesthesiologist.