With the advancement in laparoscopic techniques,increasing proficiency of Surgeons in their use and economic pressures there is an increasing trend of cholecystectomy (removal of gall bladder) being done in clinic procedures with the patients being discharged the same day. There is an interesting article in the recent British Journal of Surgery concluding day-case (i.e. no overnight stay in hospital) laparoscopic surgery to be safe and effective.
Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy.
Br J Surg. 2008; 95(2):161-8 (ISSN: 1365-2168)
Gurusamy K; Junnarkar S; Farouk M; Davidson BR
Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, University College London and Royal Free Hospital NHS Trust, London, UK. [email protected]
BACKGROUND: Although day-case laparoscopic cholecystectomy can save bed costs, its safety has to be established. The aim of this meta-analysis is to assess the advantages and disadvantages of day-case surgery compared with overnight stay in patients undergoing elective laparoscopic cholecystectomy.
METHODS: Randomized clinical trials addressing the above issue were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded and reference lists. Data were extracted from these trials by two independent reviewers. For each outcome the relative risk, weighted mean difference or standardized mean difference was calculated with 95 per cent confidence intervals based on available case analysis.
RESULTS: Five trials with 215 patients randomized to the day-case group and 214 to the overnight-stay group were included in the review. Four of the five trials were of low risk of bias. The trials recruited 49.1 per cent of patients presenting for cholecystectomy. There was no significant difference between day case and overnight stay with respect to morbidity, prolongation of hospital stay, readmission rates, pain, quality of life, patient satisfaction, and return to normal activity and work. In the day-case group 80.5 per cent of patients were discharged on the day of surgery.
CONCLUSION: Day-case laparoscopic cholecystectomy is a safe and effective treatment for symptomatic gallstones.
Such has been the practice at our center for 3 years now and there has been no cause of regret. In patient having excessive adhesions or difficult dissection or having anaesthesia related problems can be held back overnight. The patient can be assessed in the evening at the time of discharge and if comfortable can go home with instructions in case of any difficulty. I suppose the figure of 80 percent is about right.
As this study illustrates there is increasing trend towards shorter stay and early discharge. there are many centers in the US where such operations are done in office setting assisted by recent advances in intraoperative Ultrasound which is replacing cholangiography( unaware of such practice in India). Variations in the anatomy of cystic duct, hepatic duct and CBD and consequent mistakes while cutting the cystic duct can lead to dreadful and expensive complications.