Outpatient laparoscopic cholecystectomy

Feasibility and safety of day care laparoscopic cholecystectomy in a developing country

BACKGROUND

Although day care laparoscopic cholecystectomy (DCLC) has been shown to be safe in centres with adequate infrastructure for day care surgery, its feasibility and safety in developing countries has never been studied. Because of differences in the quality of health care delivery, western guidelines for day care surgery cannot be universally applied to developing countries.

PATIENTS AND METHODS

Patients less than 65 years who were graded I and II on the American Society of Anesthesiologists physical status score, irrespective of their educational status, living within 20 km, and willing to make their own arrangements for a return to hospital in case of problems were selected for DCLC. Follow up was done by patients calling the hospital the morning after surgery.

RESULTS

50% of the eligibility criteria were new; 313/383 patients were suitable for DCLC. The commonest cause for rejection was that the patient lived out of the defined area (50%). Altogether 92% were discharged within eight hours of surgery. The reasons for failure to discharge were the presence of abdominal drains in four (2%), nausea and vomiting in nine (3%), and conversion to open surgery in five (2%). Ten patients (3%) were readmitted; of these only two (<1%) had complications needing re-exploration. Analysis of results showed that the inclusion and discharge criteria were valid and that the readmission and complication rates as well as the ease and accuracy of follow up were comparable to published data. DCLC reduced waiting times and increased patient turnover and may have a positive impact on resident training.

CONCLUSIONS

DCLC is safe, feasible, and has potential benefits for health care delivery in developing countries. Each surgical service needs to develop their own guidelines based on local patient demography.

Day-only laparoscopic cholecystectomy in a regional teaching hospital

BACKGROUND

Day-only laparoscopic cholecystectomy (DOLC) has been demonstrated to be a safe and feasible procedure. The aim of the present study was to introduce DOLC to a busy teaching hospital without a separate day-surgery facility, to identify any problems associated with early discharge, and to determine patient satisfaction.

METHODS

Over a 2-year period, all patients undergoing elective laparoscopic cholecystectomy under one surgeon were prospectively studied. Patients satisfying criteria for DOLC were offered the procedure. All patients were sent anonymous satisfaction surveys postoperatively.

RESULTS

One hundred and one patients underwent elective laparoscopic cholecystectomies and 41 of these patients were booked for DOLC. Thirty-three (80%) were successfully discharged the same day and there were no complications related to early discharge. Only two of eight unplanned admissions were because of postoperative pain or nausea. Thirty-two (78%) of DOLC patients replied to our survey and of those, 24 (78%) were satisfied with their length of stay. The extra strain placed on day-stay ward resources was reflected in patient survey comments on their care.

CONCLUSIONS

Our findings support the evidence that DOLC is safe and feasible. However, in a busy teaching hospital with tight budget constraints and no separate day-surgery facility we found many patients satisfied with their length of stay but not always with the quality of care they received on the day-stay ward. The latter was insufficiently equipped to handle procedures of this complexity. So although in theory DOLC has many advantages, we are unable to institute this as routine practice at this time.

Predicting failure of outpatient laparoscopic cholecystectomy

BACKGROUND

Outpatient laparoscopic cholecystectomy (LC) is safe and feasible, but factors related to the failure of outpatient surgery are poorly defined. We hypothesized that patients in whom same day discharge (SDD) is unlikely may be identified preoperatively.

METHODS

Three hundred eighty-seven consecutive patients scheduled for elective LC were prospectively enrolled in an outpatient clinical pathway.

RESULTS

In all, 269 (70%) patients successfully underwent outpatient LC. Factors related to failure of SDD were age, American Society of Anesthesiology (ASA) class, surgery start time, and duration of surgery. Body mass index, liver function tests, and ultrasound findings did not predict failure of SDD. Three factors were able to predict more than 50% failure of SDD: age more than 50 years, ASA class 3 or more, and surgery start time later than 1:00 PM.

CONCLUSIONS

Outpatient LC is feasible in a large county hospital. These data may be used in scheduling cases and counseling patients.

Intraperitoneal pethidine versus intramuscular pethidine for the relief of pain after laparoscopic cholecystectomy: randomized trial

Laparoscopic cholecystectomy is widely used and may be performed as an ambulatory procedure. We undertook a randomized comparison of the benefits of intraperitoneal pethidine compared with intramuscular pethidine for postoperative analgesia following laparoscopic cholecystectomy. A series of 100 consecutive American Society of Anesthesiologists (ASA) I or II patients were randomly assigned to intramuscular pethidine (54 patients) or intraperitoneal pethidine (46 patients). Each was combined with intraperitoneal bupivacaine. The primary endpoints were the pain and nausea scores at intervals after operation. All recruited patients completed the study. Pain scores at rest and upon movement were significantly lower in the group receiving the intraperitoneal pethidine at each of the time periods examined (pain at rest at 4 hours: 1.6 +/- 0.8 vs. 2.4 +/- 0.9 cm; p < 0.001; pain upon movement at 4 hours: 2.1 +/- 0.9 vs. 3.1 +/- 1.2 cm; p < 0.001). The total dose of pethidine administered via patient-controlled analgesia (PCA) during the first 24 hours after surgery was also significantly lower in this group (total dose 50.9 +/- 3.9 vs. 55.9 +/- 4.4 mg; p < 0.001). There were no significant differences in the respiratory rate at any of the time periods. Intraperitoneal pethidine analgesia was superior to an equivalent dose of intramuscular pethidine for the relief of postoperative pain in patients undergoing laparoscopic cholecystectomy. This was achieved at the expense of increased nausea but no significant increase in vomiting. The accessibility of this route of analgesia administration has implications for patients undergoing laparoscopic procedures, particularly with the recent trend toward increased use of ambulatory techniques.

A new method of preemptive analgesia in laparoscopic cholecystectomy

BACKGROUND

Although laparoscopic cholecystectomy (LC) results in less pain then open cholecystectomy, it is not a pain-free procedure. The aim of this study was to test a new method of preemptive analgesia.

METHODS

By simple randomization 60 patients were assigned to two groups (30 in each group). Group A, the placebo group, received 200 ml of 0.9% saline, and group B received 5 mg/kg of a local anesthetic solution (ropivacaine) in 200 ml of 0.9% saline. Local anesthetic or placebo solution were administer before creation of the pneumoperitoneum.

RESULTS

Pain intensity, as rated by visual analog and verbal rating scales, and stress response data were significantly less in the group receiving ropivacaine than in the placebo group. No patients in treatment group received an additional dose of analgesic, whereas two patients in placebo group needed an additional analgesic.

CONCLUSIONS

Our results support the clinical validity of preemptive analgesia, but the timing of intraperitoneal administration of local anesthetic is very important. Only application before creation of the pneumoperitoneum may preempt every neuronal central sensitization.

Multimodal strategies to improve surgical outcome

OBJECTIVE

To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures.

BACKGROUND

New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated.

METHODS

We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach.

RESULTS

The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs.

CONCLUSIONS

Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.

[Outpatient laparoscopic cholecystectomy]

OUTPATIENT LAPAROSCOPIC CHOLECYSTECTOMY: The laparoscopic technique is the procedure of choice for cholecystectomy. This procedure is done on ambulatory setting in the United States and Europe but no experience was reported in France.

AIM OF THE STUDY

To report the organisation and results of our initial 100 consecutive patients operated for a laparoscopic cholecystectomy on an outpatient basis.

PATIENTS AND METHODS

After assessment of the prevention of pain and nausea or vomiting after laparoscopic cholecystectomy on hospitalized patients, a prospective trial was done on our first 100 patients for outpatient laparoscopic cholecystectomy on routine basis.

RESULTS

During the period, 27.4% of patients were entered on an ambulatory basis. 72% of patients did not need any medication post-operatively in the structure. 17 patients were admitted: in five cases, decision was done pre-operatively, one patient went back home against medical advising; in three cases, peroperatively, and in 10 cases postoperatively. Four patients were readmitted between the fifth and sixteenth post-operatoire day.

CONCLUSION

An adequate organisation for day case surgery, a good selection of patients on medical, surgical and environmental criteria, simple procedures to prevent pain or nausea vomiting post-operatively allow use to assert that hospitalisation is unjustified for laparoscopic cholecystectomy in a quater of patients.

Outpatient laparoscopic cholecystectomy. A prospective study with 100 consecutive patients

One hundred patients with cholelithiasis were included in a prospective consecutive follow-up study to evaluate laparoscopic cholecystectomy in a day surgical setting. The median operating time was 70 min. In 96% of the patients, it was possible to perform peroperative cholangiography. The median time off work was 7 days and the median time to full recovery was 14 days. Five patients were admitted due to weakness/nausea. Six patients were admitted due to conversion to open surgery or choledocholithiasis. Eighty-nine patients were treated in ambulatory surgery. We conclude that laparoscopic outpatient cholecystectomy can be performed safely with a low unplanned admission rate.

Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway

OBJECTIVE

To determine the success of a clinical pathway for outpatient laparoscopic cholecystectomy (LC) in an academic health center, and to assess the impact of pathway implementation on same-day discharge rates, safety, patient satisfaction, and resource utilization.

SUMMARY BACKGROUND DATA

Laparoscopic cholecystectomy is reported to be safe for patients and acceptable as an outpatient procedure. Whether this experience can be translated to an academic health center or larger hospital is uncertain. Clinical pathways guide the care of specific patient populations with the goal of enhancing patient care while optimizing resource utilization. The effectiveness of these pathways in achieving their goals is not well studied.

METHODS

During a 12-month period beginning April 1, 1999, all patients eligible for an elective LC (n = 177) participated in a clinical pathway developed to transition LC to an outpatient procedure. These were compared with all patients undergoing elective LC (n = 208) in the 15 months immediately before pathway implementation. Successful same-day discharges, reasons for postoperative admission, readmission rates, complications, deaths, and patient satisfaction were compared. Average length of stay and total hospital costs were calculated and compared.

RESULTS

After pathway implementation, the proportion of same-day discharges increased significantly, from 21% to 72%. Unplanned postoperative admissions decreased as experience with the pathway increased. Patient characteristics, need for readmission, complications, and deaths were not different between the groups. Patients surveyed were highly satisfied with their care. Resource utilization declined, resulting in more available inpatient beds and substantial cost savings.

CONCLUSIONS

Implementation of a clinical pathway for outpatient LC was successful, safe, and satisfying for patients. Converting LC to an outpatient procedure resulted in a significant reduction in medical resource use, including a decreased length of stay and total cost of care.

Surgical aspects and future developments of laparoscopy

Laparoscopy has revolutionized surgery and in the process influenced the practice of anesthesiology. This article reviews several minimal access procedures that have been accepted into practice, are gaining acceptance, or remain investigational. Absolute contraindications to laparoscopy have been emphasized. As the threshold for primary care physicians to refer sicker and sicker patients for surgery decreases, it is crucial for the anesthesiologist to understand physiologic stresses of pneumoperitoneum and the nuances of laparoscopic surgery. The anesthesiologist also can be recruited to adjust insufflation pressures, tweak images on monitors, rotate and position the patient, or pass balloons and bougies. With patient and surgeon expectation of no pain or nausea and early discharge, anesthetic choices become vital for the ultimate success of the procedure.

Outpatient laparoscopic cholecystectomy. Outcomes of 847 planned procedures

BACKGROUND

Cholecystectomy is now being performed on an outpatient basis at many centers. The purpose of this study was to review the results of our large experience with this procedure.

METHODS

Between 1990 and 1997, 2288 patients underwent laparoscopic cholecystectomy at our clinic. A total of 847 (37%) were scheduled as outpatients. The selection criteria for planned outpatient laparoscopic cholecystectomy called for nonfrail patients with an ASA < 4 who were living < 2 h from the hospital. All patients received detailed preoperative instruction about outpatient laparoscopic cholecystectomy. A questionnaire was sent to 309 patients to sample their opinions.

RESULTS

Since 1993, we have increased the number of planned outpatient cholecystectomies performed at our clinic, but the percentage of cholecystectomies completed on an outpatient basis has remained approximately 60%. A total of 547 of 847 operations scheduled as outpatient procedures (74.5%) were completed as planned, and 204 patients (24%) were kept in the hospital overnight. Twenty-seven (3%) were converted to open procedures. Eighteen laparoscopic patients (2%) stayed > 1 day (range, 2-20). None of the patients died. Of the 142 patients (46%) who completed our opinion survey, 66% were happy with their experience, 32% would like to have stayed in the hospital, and 2% were undecided.

CONCLUSION

Successful same-day surgery requires proper patient instruction, appropriate patient selection, and a low threshold to convert patients to inpatient status when the situation warrants. No major complications occurred as a result of same-day discharge, and two-thirds of the patients said that they preferred outpatient surgery.

MUTIRÕES DE COLECISTECTOMIA POR VIDEOLAPAROSCOPIA EM REGIME DE CIRURGIA AMBULATORIAL

Introdução: As listas de espera para colecistectomia, associadas à elevada demanda dos leitos e salas cirúrgicas dos Hospitais Universitários, são incentivos para adoção de novos programas de assistência. Objetivo: Avaliar o processo de organização e os resultados clínicos dos Mutirões de Colecistectomia por Videolaparoscopia, em regime de Cirurgia Ambulatorial. Pacientes e Métodos: Dentre os 314 pacientes portadores de colelitíase sintomática que aguardavam cirurgia no HCFMRP-USP, 160 foram selecionados para tratamento em regime ambulatorial. Uma equipe multiprofissional, formada por cirurgiões, anestesistas, enfermeiros e assistentes sociais, programou 4 mutirões para serem realizados em fins de semana, em função da disponibilidade do bloco cirúrgico e da sala de recuperação pós-anestésica. Mediante avaliação retrospectiva, foram analisados 79 prontuários dos pacientes operados nos Mutirões I e II (Grupo A) e 79 dos 80 operados nos Mutirões III e IV (Grupo B). Análise estatística: teste de Wilcoxon e exato de Fisher (p<0,05). Resultados: As co-morbidades foram registradas em 48 pacientes do Grupo A - (60,8%) e em 31 do Grupo B (39,8%) (p=0,007). A inflamação aguda e a escleroatrofia da vesícula foram observadas em 10 pacientes do Grupo A (12,7%) e em 2 do Grupo B (2,6%). A duração média das operações, em minutos, foi de 90 (25-240) no Grupo A e de 68,2 (20-180) no Grupo B (p=0,002). Houve uma conversão em cada Grupo (1,3%). A profilaxia da dor e dos vômitos foi realizada, respectivamente, em 13 (16,4%) e em 2 (2,5%) pacientes do Grupo A. No Grupo B, 63 pacientes (79,7%) receberam analgésicos e 73 (92,5%) antieméticos de forma profilática. A dor abdominal, os vômitos e os sintomas cardiorespiratórios, na recuperação pós-anestésica, acometeram, respectivamente, 34 (43%), 18 (22,6%) e 10 (12,6%) dos pacientes do Grupo A e 18 (22,8%), 14 (17,7%) e 3 (3,8%) do Grupo B. A necessidade de pernoite foi maior no Grupo A: 45 pacientes (50,7%) com permanência hospitalar média de 18,3 horas (8,2-26), enquanto no Grupo B houve 5 pernoites e a média de permanência foi de 7,5 horas (4-24) (p=0,000). Ocorreram 5 internações no Grupo A (6,3%) e 2 no Grupo B (2,5%). A reavaliação médica, na primeira semana, foi necessária em 8 pacientes do Grupo A (10,2%) e redundou em 3 readmissões (3,8%). No Grupo B, 2 pacientes (2,6%) procuraram o serviço de saúde e a readmissão não foi necessária. No Grupo A, 2 pacientes apresentaram coleperitônio e 1 foi reoperado; não houve óbitos em nenhum Grupo. Conclusão: O aprimoramento no processo de seleção e nos cuidados perioperatórios para colecistectomia videolaparoscópica, em regime ambulatorial, assegura o tratamento, na forma de mutirões, como estratégia eventual de redução das listas de espera.

Day-case laparoscopic fundoplication for gastro-oesophageal reflux disease

BACKGROUND

Based on a series of successful outpatient laparoscopic cholecystectomies, day-case laparoscopic fundoplication for gastro-oesophageal reflux disease was introduced in January 1997. The initial results are reported.

METHODS

Inclusion criteria were American Society of Anesthesiologists grade I-II, living within 30 min travel from the hospital, and adult company at home. Initially only selected patients were offered day-case treatment, but later it was adopted as routine. The patients underwent general intravenous anaesthesia with propofol and remifentanil, and were given ketorolac, propacetamol, droperidol and ondansetron as prophylaxis against postoperative pain and nausea. The surgical procedure was Nissen-Rosetti fundoplication or semifundoplication depending on oesophageal manometric results.

RESULTS

Forty-five patients were included. Four patients were admitted; 41 were discharged as planned 3-8 h after operation, and five of these patients were readmitted. One underwent reoperation for necrosis of the gastric fundus. A further five patients visited the outpatient department without need for admission. At follow-up 31 patients were satisfied with the day-case treatment, five were indifferent, and five were dissatisfied because of pain. If offered a similar operation in the future, 26 patients would have preferred and seven would have accepted day-case treatment, and eight would not.

CONCLUSION

Outpatient laparoscopic fundoplication is safe and well tolerated by the majority of patients.

Audit of outpatient laparoscopic cholecystectomy. Universities of Melbourne HPB Group

BACKGROUND

Because the postoperative stay after laparoscopic cholecystectomy (LC) has shortened, it seemed that outpatient LC would be feasible. The aim of this study was to prospectively audit initial experience with outpatient LC at the Austin and Repatriation Medical Centre. We aimed to determine appropriate patient selection criteria, to devise anaesthetic and discharge protocols and to assess patient satisfaction at follow up.

METHODS

All patients presenting for LC were assessed for suitability, and those elective cases unlikely to have a duct stone and fulfilling the social criteria were studied. After standard anaesthetic and LC technique, patients recovered in the day surgery unit for up to 8 h and were discharged if stable. The hospital in the home nursing service monitored patients for 48 h and arranged readmission if needed. Patient satisfaction was assessed by independent telephone questionnaire 6 weeks postoperatively.

RESULTS

Forty-five patients (median age 43 years) underwent outpatient LC with a discharge rate of 82.3%, resulting in a cost saving of $984 per patient treated. One patient was readmitted, giving an overall success rate of 80%. After stricter implementation of the protocol in the second half of the study, the discharge rate rose to 92%. Patient acceptance of the technique was high at 84.5%.

CONCLUSIONS

The results of the first 45 patients show that it is possible to safely perform outpatient LC with a low admission rate in fit, elective patients who live close to medical care. Provided a strict anaesthetic protocol is followed, the technique has good patient acceptance and provides some economic benefit to the hospital.

Pain after laparoscopic cholecystectomy

BACKGROUND

Although laparoscopic cholecystectomy (LC) results in less pain than open chole-cystectomy, it is not a pain-free procedure. Many methods of analgesia for pain after laparoscopy have been evaluated.

METHODS

Forty-two randomized controlled trials assessing interventions to reduce pain after LC are reviewed, as are the mechanisms and nature of pain after this procedure.

RESULTS

Non-steroidal anti-inflammatory drugs, wound local anaesthetic, intraperitoneal local anaesthetic, intraperitoneal saline, a gas drain, heated gas, low-pressure gas and nitrous oxide pneumo-peritoneum have been shown to reduce pain after LC. The clinical significance of this pain reduction is questionable.

CONCLUSION

Pain after LC is multifactorial. Although many methods of analgesia produce short-term benefit, this does not equate with earlier discharge or improved postoperative function. However, single trials evaluating low-pressure insufflation, heated gas and multimodal analgesia suggest that clinically relevant benefits can be achieved.

A prospective randomized trial of day-stay only versus overnight-stay laparoscopic cholecystectomy

BACKGROUND

Although the feasibility of laparoscopic cholecystectomy performed as day surgery has been established, cost and recovery time have not previously been evaluated in a prospective comparative fashion.

METHODS

Patients were randomized to day stay only or overnight stay, and a nurse assessed the former postoperatively at home. All patients were reviewed weekly or as required if problems occurred. Costing comparisons were made between the two groups using Trendstar software.

RESULTS

A total of 131 patients were evaluated after randomization (60 day-stay only patients and 71 overnight-stay patients). A total of 18.3% of the day-stay patients required in-hospital admission for nausea, vomiting, or pain, or after conversion to open operation; 18.3% of the overnight group required an extended length of stay for similar reasons. After discharge, two day-stay and three overnight-stay patients required readmission, only one had a significant complication. The mean times to return to normal activity averaged 1.8 weeks (SE: 0.1 weeks) and 1.9 weeks (SE: 0.1 weeks) for day-stay and overnight-stay groups, respectively (P = 0.63), and costs of $2732 (SE: $76) compared to $2835 (SE $110), respectively (P = 0.94).

CONCLUSIONS

In the present randomized controlled study, day-stay management did not compromise postoperative patient outcome. In the setting of a major teaching hospital there was no cost advantage when compared to overnight-stay management.

Biliary tract surgery

The use of the laparoscope in biliary tract surgery continues to play a major role in improving the operative management of patients with biliary diseases. Laparascopic cholecystectomy has been safely performed as a day-case procedure and has lowered the morbidity of cholecystectomy in the setting of acute cholecystitis. Laparoscopic common bile duct exploration allows cholecystectomy and the removal of common bile duct stones to be performed during the same procedure, thereby decreasing hospital stay. Several new noninvasive modalities have been recently developed to image the biliary tract. In addition, laparoscopic ultrasound has led to rapid intraoperative imaging of the extrahepatic biliary tree. The long-term results of laparoscopic bile duct injuries have been better defined during the past several years. Finally, the role of surgical resection for gallbladder cancer detected during or after laparoscopic cholecystectomy has recently been evaluated.

Laparoscopic biliary surgery

Treatment of gallstones by laparoscopic cholecystectomy has become standard therapy over the past decade and has received wide patient acceptance. Problems are infrequent but those such as biliary injury may be serious and continue to be a cause of concern. Biliary injury is more likely when surgery is performed in the presence of acute inflammation. Laparoscopic bile duct exploration is becoming standardized and the results are good. The role of other laparoscopic biliary procedures such as biliary bypass is still uncertain.

Laparoscopic cholecystectomy as a "true" outpatient procedure: initial experience in 130 consecutive patients

Laparoscopic cholecystectomy has received nearly universal acceptance and is currently considered the "gold standard" for the treatment of cholelithiasis. Many centers have employed "short-stay" units or "23-hour admissions" for postoperative observation following laparoscopic cholecystectomy. The practice of early discharge as "true" outpatients following this procedure has not been well defined. A retrospective analysis of 130 consecutive patients undergoing laparoscopic cholecystectomy in an outpatient surgery unit was performed. A follow-up telephone survey was carried out of patients who successfully completed the procedure as outpatients. One hundred thirty patients underwent outpatient laparoscopic cholecystectomy. The patient population consisted of 78% women, with an age range of 17 to 76 years (mean age 47.1 years). Symptomatic gallstone disease was the indication for laparoscopic cholecystectomy in 92% of the patients. All patients underwent successful completion of laparoscopic cholecystectomy with no conversions to an open procedure. The mean length of operation was 75 +/- 23 minutes (range 25 to 147 minutes). The mean length of stay in the postanesthesia care unit (PACU) ranged from 95 to 460 minutes with a mean length of stay of 200 +/- 79 minutes. A total of eight patients (6.2%) were admitted to the hospital directly from the PACU in the immediate postoperative period. Six of these eight patients were discharged on the first postoperative day. Following discharge from the PACU, an additional six patients (4.6%) required hospital admission. Three of these six patients were discharged after a single day of hospitalization. Ninety-eight of 116 eligible patients were available for follow-up telephone evaluation. The outpatient experience was rated as good by 75.5% of the patients, fair by 22.5%, and poor by 2%. In retrospect, 20.4% of the patients stated that they would have preferred an inpatient to an outpatient procedure. Laparoscopic cholecystectomy can be performed as a true outpatient procedure with patients discharged to home within hours of completion of the procedure. Less than 10% of patients will fail this protocol and another 5% of the patients may require hospitalization after returning to their homes.

Extending the limits: minimally invasive surgery

Minimally invasive technology is being applied to an increasing number of surgical procedures. It remains to be seen which techniques will eventually become a 'gold standard' as has the laparoscopic cholecystectomy, and which will fall by the wayside. In the meantime, anesthesiologists must be aware of the unique requirements and complications of laparoscopic surgery.

Desflurane versus propofol maintenance for outpatient laparoscopic cholecystectomy

BACKGROUND

The aims of the study were to evaluate costs and clinical characteristics of desflurane-based anaesthetic maintenance versus propofol for outpatient cholecystectomy.

METHODS

All 60 patients received ketamine 0.2 mg kg(-1), fentanyl 2 microg kg(-1) and propofol 2 mg kg(-1) for induction. Ketorolac 0.4 mg kg(-1) and ondansetron 0.05 mg kg(-1) +droperidol 20 microg kg(-1) was given as prophylaxis for postoperative pain and emesis, respectively. The patients were randomly assigned into Group P with propofol maintenance and opioid supplements, or Group D with desflurane in a low-flow circuit system.

RESULTS

All the patients were successfully discharged within 8 h without any serious complications. Emergence from anaesthesia was more rapid after desflurane; they opened their eyes and stated date of birth at mean 6.4 and 8.4 min respectively, compared with 9.6 and 12 min in the propofol group (P<0.05). Nausea and pain were more frequent in Group D, 40% and 80% respectively; versus 17% and 50% in Group P (P<0.05). By telephone interview at 24 h and 7 d after the procedure, there was no major difference between the groups. With desflurane, drug costs per case were 10 $ lower than with propofol.

CONCLUSION

We conclude that desflurane is cheaper and has a more rapid emergence than propofol for outpatient cholecystectomy. However, propofol results in less pain and nausea in the recovery unit. Despite ondansetron and droperidol prophylaxis, there was still a substantial amount of nausea and vomiting after desflurane.