Laparoscopic Cholecystectomy as an Outpa t ien t Procedure

David Lam, MD, Rodrigo Miranda, MI), FACS, and Shirley J. Horn, PA-C

Background: Laparoscopic cholecystectomy is st i l l done mainly on an inpatient basis at hospitals or on an out- patient basis at ambulatory care departments inside hospitals.

Study Design: We reviewed 213 cases in which outpatient laparoscopic cholecystectomy was done at an ambula- tory surgical center not associated wi th a hospital phys- ically or administratively. Patients were selected solely on the basis o f medical history and physical examina- t i o n results. Patients received general anesthesia as is

typ ica l for outpatient procedures . Narcotic use was minimized to prevent postoperative nausea. The proce- dure did not include intraoperative c h o l a n g i o g r a p h y .

Results: Laparoscopic cholecystectomy took 1 to 2 hours in three quarters of patients. Rate of conversion to open cholecystectomy was 2.8% (6 of 213 patients). The mean recovery period was 6.6 hours, and 97% of patients were discharged on the same day (ie, were treated as outpatients). We identified no cases of re- tained common duct stone. Wound complications in- cluded mainly seroma, wound seepage, and wound in- fection; 18% of these complications were seen at trocar sites. No major complications were seen.

Conclusions: Elective outpatient laparoscopic cholecys- tectomy can be done safely with low morbidity, high patient acceptance, and same-day discharge in > 95% of cases. (J Am Coll Surg 1997;185:152-155. © 1997 by the American College of Surgeons)

In recent years, laparoscopy has become a stan- dard technique used in cholecystectomy, a l though inability to identify impor tant anatomic structures necessitates intraoperative cholangiogram or con- version to an open procedure for cholecystectomy. Use of laparoscopy in cholecystectomy can reduce surgery time and hospital stay. Consequently, most patients having laparoscopic cholecystectomy are discharged on the same day. Laparoscopic chole- cystectomy is nevertheless usually still done ei ther as an inpat ient p rocedure at a hospital or as an

outpat ient procedure at an ambulatory Care de- par tment inside a hospital.

We reviewed our experience with outpat ient laparoscopic cholecystectomy done at a private ambulatory care center external to a hospital. From May 1994 to May 1996, 213 patients were scheduled to have laparoscopic cholecystectomy as outpatients at this privately owned ambulatory sur- gical center.

The Ambulatory Surgical Center

The surgical center with which our medical group contracted is a corporation-owned, freestanding building not associated with any hospital physically or administratively. The nearest hospital is located ¾ miles away. Since May 1994, we have used the center to per form laparoscopic cholecystectomy as an outpat ient service (ie, pat ient remains in cen- ter -- 23 hours).

Selection of Patients

Our study included 213 patients who had under- gone laparoscopic cholecystectomy between May 1994 and May 1996. In 211 patients, sonograms showed gallstones. One had an abnormal oral cho- lecystogram; 1 had cholecystectomy on the basis of typical biliary symptoms. No pat ient had a previ- ous upper abdominal operation. Selection criteria for outpat ient laparoscopic cholecystectomy in- c luded history of symptomatic cholelithiasis or cholecystitis but no acute signs or symptoms when scheduled for elective outpat ient surgery. Patients were admit ted to the hospital if they had clinically significant pain, history of elevated leukocyte count, abnormal liver funct ion test results (or- dered selectively by referral sources), or clinically significant cardiopulmonary disease requir ing spe- cialized perioperative monitoring.

Operative Techniques

Received December 2, 1996; Revised March 31, 1997; Accepted April 1, 1997. From the Department of Surgery, Kaiser Permanente Medical Of- rices, Bakersfield, CA. Correspondence address: David Lain, MD, Department of Surgery, Kaiser Permanente Medical Offices, PO Box 12099, Bakersfield, CA 93389-1299.

Patients were anesthetized using propofol (Diprivan, Stuart Pharmaceuticals, Wilmington, DE), then orally intubated after adequate muscle relaxation was achieved. Anesthesia was mainta ined using an inhalation agent (isofiurane), nitrous oxide, and a

© 1997 by the American College of Surgeons ISSN 1072-7515/97/$17.00 Published by Elsevier Science Inc. 1 52 PII S1072-7515 (97)00041-0

T a b l e 1. C o n v e r s i o n o f L a p a r o s c o p i c to O p e n C h o l e c y s t e c t o m y *

L a m e t al

Cause No. of patients

Severe gallbladder inflammation or gangrene 3 Severe adhesion 1 Spillage of large calculi 1 Unclear anatomy 1

*Total number of patients who underwent laparoscopic cholecystectomy at ambulatory surgery center was 213.

small dose of a narcotic agent. Parenteral ketoro- lac t romethamine (Toradol, Syntex Laboratories, Inc, Humacao, PR) was given either before the p rocedure or about 15 minutes before its conclusion.

The procedure was done without intraoperative cholangiography. The cystic duct and artery were identified by dissection, which cleared all tissues between the medial edge of the gallbladder and the c o m m o n bile duct. The c o m m o n bile duct itself cannot always be seen, but continuity f rom the neck of the gallbladder to the cystic duct must be ascertained before clipping to prevent injury to a tented c o m m o n bile duct. No local anesthesia was given at trocar sites either preoperatively or postoperatively, and the peri toneal cavity was not irrigated with any anesthetic agent before closure.

At arrival in the recovery room, most patients were given a laparoscopic cholecystectomy cock- tail of metoclopramide hydrochloride (Reglan, A. H. Robins Company, Richmond, VA) and pro- chlorperazine (Compazine, SmithKline Beecham Pharmaceuticals, Philadelphia, PA). Nurses fol- lowed a standard postoperative protocol fo r addi- tional management .

OUTPATIENT LAPAROSCOPIC CHOLECYSTECTOMY 153

Tab le 2. Rate o f P o s t o p e r a t i v e C o m p l i c a t i o n s in a Ser ies o f 213 O u t p a t i e n t L a p a r o s c o p i c C h o l e c y s t e c t o m i e s at an A m b u l a t o r y Surgica l C e n t e r

No. of Type of complication complications

Retained CBD calculi 0* CBD injury 0 Complications of wound healing at trocar site

Seroma 17 Hematoma 1 Infection 20 Total 38 (18%)

*Postoperative symptoms suggestive of biliary causes were evaluated by sono- gram and liver function tests. Only one patient evaluated had results within normal limits and spontaneous resolution of pain.

CBD, common bile duct.

Results

Six (2.8%) of 213 patients required conversion to open cholecystectomy. Table 1 shows the causes of the conversions. For the 207 successful laparo- scopic cholecystectomy procedures, operative time was < 1 hou r in 52 patients (25%), 1-2 hours in 151 patients (73%), and > 2 hours in 4 patients (2%).

Of 213 patients, 206 (97%) were discharged on the same day and so can be considered outpa- tients. Length of stay in the recovery room (Fig. 1) ranged from 2 to > 12 hours (mean 6.6 hours). Table 2 shows rate of postoperative complications.

Discussion

Elective laparoscopic cholecystectomy can be ef- fective as an outpat ient procedure if patients are selected appropriately for the outpat ient ap-

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FIG 1. L e n g t h o f stay in r ecove ry r o o m fo r pa t i en t s u n d e r g o i n g l a p a r o s c o p i c c h o l e c y s t e c t o m y as a n o u t p a t i e n t p r o c e d u r e .

154 J AM COLL SUNG AUGUST 1997 VOLUME 185:152--155

proach and if the perioperative techniques used shorten postoperative recovery. The outpat ient ap- proach can be considered a practical and success- ful choice if rates of morbidity and conversion to open procedure are comparable with those seen in the hospital setting, if the length of stay is appropriate for the outpat ient setting, and if pa- tients are satisfied with their care.

We comple ted 206 of 213 laparoscopic cholecys- tectomy cases on an outpat ient basis. The other 7 cases included 6 conversions to open cholecystec- tomy and 1 case of a pat ient with insulin- d e p e n d e n t diabetes mellitus who decided to stay overnight.

Patients were referred to us from primary care offices, and gallbladder ul trasonography reports were usually at tached to the medical charts. On the basis of medical history, physical examination, a n d results of liver funct ion tests (some done at primary care offices), the patients who did no t have cholecystitis or choledocholithiasis were se- lected for elective outpat ient laparoscopic chole- cystectomy. Only a rout ine complete blood cell count was done preoperatively, and we did no t cancel any cholecystectomy on the basis of hemo- gram results. Some patients had mildly dilated c o m m o n bile ducts (10 m m +__ 1 mm) , but this condit ion did not preclude patients f rom elective outpat ient laparoscopic cholecystectomy. Koo and Traverso (1) no ted a 12% prevalence rate for com- m o n bile duct calculi in patients undergo ing lapa- roscopic cholecystectomy and found that medical history (ie, of jaundice, pancreatitis, and known elevated results of liver funct ion tests associated with previous biliary pain) had the highest positive predictive value for the presence of c o m m o n bile duct stones. Stain and colleagues (2) found that elevated levels of alkaline phosphatase and a total bilirubin level h igher than twice the normal level had a 55% positive predictive value for c o m m o n bile duct calculi.

Liver funct ion tests were obtained for any pa- t ient whose medical history suggested c o m m o n bile duct calculi. If test results showed elevated levels of alkaline phosphatase and total bilirubin, the pat ient was admit ted to the hospital for pre- operative endoscopic retrograde cholangiopan- creatography and laparoscopic cholecystectomy.

Patients received the same general anesthesia as is routinely adminis tered to patients having outpa- t ient procedures. Emphasis was placed on short- acting, gaseous, and injectable anesthetic agents and minimal use of narcotic agents. Parenteral injection of ketorolac t romethamine (Toradol) is increasingly being used for postanesthesia pain

control. Recent application of preemptive analge- sic techniques such as injecting long-acting local anesthetic agents into trocar sites might fur ther reduce postoperative pain and the resultant need for postoperative stay along with associated nar- cotic use and nausea (3).

In a pat ient series f rom Georgia Baptist Medical Center (4), selective intraoperative cholangiogra- phy was done in 10.8% of patients to confirm presence of c o m m o n bile duct calculi and to de- lineate anatomy. We did no t use intraoperative cholangiography but instead relied on our preop- erative patient selection procedure and on clear identification of the cystic duct in relation to Hart- mann ' s pouch. Our series inc luded no c o m m o n bile duct injury and no re ta ined c o m m o n bile duct calculi as de te rmined on the basis of longterm clinical outcome. The Mayo Clinic (5) repor ted a 0.6% incidence rate for retained c o m m o n bile duct calculi detected by using selective intraoper- ative cholangiography. A 0.2% incidence rate for retained c o m m o n bile duct calculi was repor ted by Soper and colleagues (6), who per fo rmed selec- tive intraoperative cholangiography in 30% of their patients. We followed up our patients post- operatively until they had recovered completely f rom biliary problems. In one pat ient whose post- operative pain was evaluated by liver funct ion tests and a gallbladder sonogram (which p roduced negative results), pain resolved spontaneously.

In their series of 424 patients, Soper and col- leagues (6) repor ted a 2.9% rate of minor compli- cations, a 1.5% rate of major complications, and one minor injury to the c o m m o n bile duct. The Georgia group repor ted no bile duct injury in 1,525 patients and a 4% rate of major complica- tions (4). Our series of 213 patients included no c o m m o n bile duct injury, no major complications, and an 18% rate of minor complications, most of which were related to wound healing at trocar sites. The lack of major complications in our series derived from the restrictive selection criteria we used to de termine which patients were candidates for outpat ient laparoscopic cholecystectomy. The patients selected for outpat ient laparoscopic cho- lecystectomy had the simplest clinical history, nor- mal physical examinat ion results, and no clinically significant medical risks (they were in American Surgical Association classes 1 and 2 only).

In our series, 97% of patients were treated as outpatients (ie, discharged on the same day); length of stay in the recovery room averaged 6.6 hours. In the Georgia series, 37% of patients were treated as outpatients, and mean length of hospi- tal stay was .82 days (4). In a repor t by Rutledge

Lam et al OUTPATIENT LAPAROSCOPIC CHOLECYSTECTOIVlY 155

and colleagues (7), mean length of hospital stay for elective laparoscopic cholecystectomy was 1.8 days.

The Georgia group 's 2.2% rate of conversion to open cholecystectomy (4) and Soper and Dun- negan ' s 1.9% incidence rate for conversion (6) are comparable with our 2.8% rate. Wherry and colleagues (8) listed three main factors affecting risk of conversion to open cholecystectomy: cho- ledocholithiasis, acute cholecystitis, and aberrant anatomy.

In our series, all patients received a postopera- tive survey by mail. We received only positive com- ments f rom outpa t ien t laparoscopic cholecystec- tomy patients. The competence and the caring at t i tude of the recovery room nursing staff were often m e n t i o n e d as the reasons for smooth pat ient recovery f rom anesthesia. We received no com- plaints of p remature discharge f rom the hospital.

The patients whose procedures were converted to open cholecystectomy were immediate ly trans- fer red to the inpat ient care uni t at a nearby hos- pital via ambulance, where they stayed 1-2 days unt i l they were able to eat and pain became man- ageable with oral analgesic agents.

Summary

Elective laparoscopic cholecystectomy is prefera- bly done on an outpa t ien t basis. Candidates for the procedure can be selected appropriately solely on the basis of medical history and physical exam- inat ion results. The procedure can be done safely

and can result in low morbidity, a high degree of pat ient satisfaction, and same-day discharge f rom the hospital in > 95% of cases.

Acknowledgments

We would like to thank the staff of Heal th South, Physicians Plaza Surgical Center, who assisted with the study, and the Medical Editing Department , Kaiser Founda t ion Research Institute, who pro- vided editorial assistance.

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