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Laparoscopic cholecystectomy as an outpatient procedure
Laparoscopic Cholecystectomy as an O u t p a t i e n t P r o c e d u r e David Lam, MD, Rodrigo Miranda, MI), FACS,and Shirley J. Horn, PA-C Background:Laparoscopic cholecystectomy is still d o n e mainly o n an inpatient basis at hospitals or o n an outpatient basis at ambulatory care departments inside hospitals.
outpatient p r o c e d u r e at an ambulatory Care dep a r t m e n t inside a hospital. We reviewed our experience with outpatient laparoscopic cholecystectomy d o n e 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 surgical center.
Study Design:We reviewed 213 cases in which outpatient laparoscopic cholecystectomy was d o n e at an ambulatory surgical center n o t associated w i t h a hospital physically or administratively. Patients were selected solely on the basis o f medical history and physical examinat i o n results. Patients received general anesthesia as is t y p i c a l for outpatient procedures. Narcotic use was m i n i m i z e d to prevent postoperative nausea. T h e procedure did not include intraoperative c h o l a n g i o g r a p h y .
The Ambulatory Surgical Center
The surgical center with which our medical group contracted is a corporation-owned, freestanding building n o t associated with any hospital physically or administratively. T h e nearest hospital is located ¾ miles away. Since May 1994, we have used the center to p e r f o r m laparoscopic cholecystectomy as an outpatient service (ie, patient remains in center -- 23 hours).
Results: Laparoscopic cholecystectomy took 1 to 2 hours
in three quarters of patients. Rate of conversion to o p e n cholecystectomy was 2.8% (6 of 213 patients). The mean recovery period was 6.6 hours, and 97% o f patients were discharged on the same day (ie, were treated as outpatients). We identified no cases of retained c o m m o n duct stone. Wound complications included mainly seroma, w o u n d seepage, and wound infection; 18% o f these complications were seen at trocar sites. N o major complications were seen.
Selection of Patients
O u r study included 213 patients who h a d undergone laparoscopic cholecystectomy between May 1994 and May 1996. In 211 patients, sonograms showed gallstones. O n e had an abnormal oral cholecystogram; 1 h a d cholecystectomy on the basis of typical biliary symptoms. No patient had a previous u p p e r abdominal operation. Selection criteria for outpatient laparoscopic cholecystectomy included history of symptomatic cholelithiasis or cholecystitis but no acute signs or symptoms when scheduled for elective outpatient surgery. Patients were admitted to the hospital if they had clinically significant pain, history of elevated leukocyte count, abnormal liver function test results (ordered selectively by referral sources), or clinically significant cardiopulmonary disease requiring specialized perioperative monitoring.
Conclusions: Elective outpatient laparoscopic cholecystectomy 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 b e c o m e a standard technique used in cholecystectomy, although inability to identify i m p o r t a n t anatomic structures necessitates intraoperative cholangiogram or conversion to an o p e n p r o c e d u r e for cholecystectomy. Use of laparoscopy in cholecystectomy can reduce surgery time and hospital stay. Consequently, most patients having laparoscopic cholecystectomy are discharged on t h e same day. Laparoscopic cholecystectomy is nevertheless usually still d o n e either as an inpatient p r o c e d u r e at a hospital or as an
Operative Techniques
Patients were anesthetized using propofol (Diprivan, Stuart Pharmaceuticals, Wilmington, DE), then orally intubated after adequate muscle relaxation was achieved. Anesthesia was m a i n t a i n e d using an inhalation agent (isofiurane), nitrous oxide, and a
Received December 2, 1996; Revised March 31, 1997; Accepted April 1, 1997. From the Department of Surgery, Kaiser Permanente Medical Ofrices, Bakersfield, CA. Correspondence address: David Lain, MD, Department of Surgery, Kaiser Permanente Medical Offices, PO Box 12099, Bakersfield, CA 93389-1299. © 1997 by the American College of Surgeons Published by Elsevier Science Inc.
1 52
ISSN 1072-7515/97/$17.00 PII S1072-7515 (97)00041-0
L a m e t al 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 Cholecystectomy* Cause
No. of patients
Severe gallbladder inflammation or gangrene Severe adhesion Spillage of large calculi Unclear anatomy
3 1 1 1
small dose of a narcotic agent. Parenteral ketorolac t r o m e t h a m i n e (Toradol, Syntex Laboratories, Inc, Humacao, PR) was given either before the p r o c e d u r e or about 15 minutes before its conclusion. T h e p r o c e d u r e was d o n e without intraoperative cholangiography. T h e 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. T h e c o m m o n bile duct itself c a n n o t always be seen, but continuity from the neck of the gallbladder to the cystic duct must be ascertained before clipping to prevent injury to a t e n t e d c o m m o n bile duct. No local anesthesia was given at trocar sites either preoperatively or postoperatively, and the peritoneal cavity was n o t irrigated with any anesthetic agent before closure. At arrival in the recovery room, most patients were given a laparoscopic cholecystectomy cocktail of m e t o c l o p r a m i d e hydrochloride (Reglan, A. H. Robins Company, Richmond, VA) and prochlorperazine (Compazine, SmithKline Beecham Pharmaceuticals, Philadelphia, PA). Nurses followed a standard postoperative protocol f o r additional m a n a g e m e n t .
e,
Q.
o '-
"-
E :3 z
153
T a b l e 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 S e r i e s 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 a n A m b u l a t o r y Surgical C e n t e r No. of complications
Type of complication
*Total number of patients who underwent laparoscopic cholecystectomy at ambulatory surgery center was 213.
.~
OUTPATIENT LAPAROSCOPIC CHOLECYSTECTOMY
Retained CBD calculi CBD injury Complications of w o u n d healing at trocar site Seroma Hematoma Infection Total
0* 0 17 1 20 38 (18%)
*Postoperative symptoms suggestive of biliary causes were evaluated by sonogram 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 o p e n cholecystectomy. Table 1 shows the causes of the conversions. For the 207 successful laparoscopic cholecystectomy procedures, operative time was < 1 h o u 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 a n d so can be considered outpatients. Length of stay in the recovery r o o m (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 effective as an outpatient p r o c e d u r e if patients are selected appropriately for the outpatient ap-
100 90 80 70 60 50 40 30 20 10 0 2h
4h
6h
8h
1Oh
12h
>12h
Length of stay (hr) FIG 1. L e n g t h o f stay in r e c o v e r y r o o m f o r p a t i e n 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 AUGUST1997
VOLUME185:152--155
proach and if the perioperative techniques used shorten postoperative recovery. The outpatient app r o a c h can be considered a practical and successful choice if rates of morbidity and conversion to o p e n p r o c e d u r e are comparable with those seen in the hospital setting, if the length of stay is appropriate for the outpatient setting, and if patients are satisfied with their care. We c o m p l e t e d 206 of 213 laparoscopic cholecystectomy cases on an outpatient basis. T h e other 7 cases included 6 conversions to o p e n cholecystectomy and 1 case of a patient with insulind 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 ultrasonography reports were usually attached to the medical charts. O n the basis of medical history, physical examination, a n d results of liver function tests (some d o n e at primary care offices), the patients who did n o t have cholecystitis or choledocholithiasis were selected for elective outpatient laparoscopic cholecystectomy. Only a routine complete blood cell count was d o n e preoperatively, and we did n o t cancel any cholecystectomy on the basis of hemogram results. Some patients had mildly dilated c o m m o n bile ducts (10 m m +__ 1 m m ) , but this condition did n o t preclude patients from elective outpatient laparoscopic cholecystectomy. Koo a n d Traverso (1) n o t e d a 12% prevalence rate for comm o n bile duct calculi in patients u n d e r g o i n g laparoscopic cholecystectomy and f o u n d that medical history (ie, of jaundice, pancreatitis, and known elevated results of liver function 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) f o u n d that elevated levels of alkaline phosphatase and a total bilirubin level higher than twice the normal level had a 55% positive predictive value for c o m m o n bile duct calculi. Liver function tests were obtained for any patient 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 patient was admitted to the hospital for preoperative endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Patients received the same general anesthesia as is routinely administered to patients having outpatient procedures. Emphasis was placed on shortacting, gaseous, a n d injectable anesthetic agents and minimal use of narcotic agents. Parenteral injection of ketorolac t r o m e t h a m i n e (Toradol) is increasingly being used for postanesthesia pain
control. Recent application of preemptive analgesic techniques such as injecting long-acting local anesthetic agents into trocar sites might further reduce postoperative pain a n d the resultant n e e d for postoperative stay along with associated narcotic use and nausea (3). In a patient series from Georgia Baptist Medical Center (4), selective intraoperative cholangiography was d o n e in 10.8% of patients to confirm presence of c o m m o n bile duct calculi a n d to delineate anatomy. We did n o t use intraoperative cholangiography but instead relied on o u r preoperative patient selection p r o c e d u r e and on clear identification of the cystic duct in relation to Hartm a n n ' s pouch. O u r series included no c o m m o n bile duct injury a n d no retained c o m m o n bile duct calculi as d e t e r m i n e d on the basis of longterm clinical outcome. The Mayo Clinic (5) r e p o r t e d a 0.6% incidence rate for retained c o m m o n bile duct calculi detected by using selective intraoperative cholangiography. A 0.2% incidence rate for retained c o m m o n bile duct calculi was reported by Soper and colleagues (6), who p e r f o r m e d selective intraoperative cholangiography in 30% of their patients. We followed u p our patients postoperatively until they had recovered completely from biliary problems. In one patient whose postoperative pain was evaluated by liver function tests and a gallbladder sonogram (which p r o d u c e d negative results), pain resolved spontaneously. In their series of 424 patients, Soper and colleagues (6) reported a 2.9% rate of m i n o r complications, a 1.5% rate of major complications, and one m i n o r injury to the c o m m o n bile duct. T h e Georgia group r e p o r t e d no bile duct injury in 1,525 patients and a 4% rate of major complications (4). O u r series of 213 patients included no c o m m o n bile duct injury, no major complications, and an 18% rate of m i n o r complications, most of which were related to w o u n d healing at trocar sites. T h e lack of major complications in o u r series derived from the restrictive selection criteria we used to d e t e r m i n e which patients were candidates for outpatient laparoscopic cholecystectomy. T h e patients selected for outpatient laparoscopic cholecystectomy had the simplest clinical history, normal physical examination 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 r o o m averaged 6.6 hours. In the Georgia series, 37% of patients were treated as outpatients, and m e a n length of hospital stay was .82 days (4). In a r e p o r t by Rutledge
L a m et al a n d colleagues (7), m e a n l e n g t h of hospital stay for elective laparoscopic cholecystectomy was 1.8 days. T h e Georgia g r o u p ' s 2.2% rate o f conversion to o p e n cholecystectomy (4) a n d Soper a n d Dunn e g a n ' s 1.9% incidence rate for conversion (6) are comparable with our 2.8% rate. W h e r r y a n d colleagues (8) listed three m a i n factors affecting risk o f conversion to o p e n cholecystectomy: choledocholithiasis, acute cholecystitis, a n d a b e r r a n t anatomy. In o u r series, all patients received a postoperative survey by mail. We received only positive comm e n t s f r o m o u t p a t i e n t laparoscopic cholecystect o m y patients. T h e c o m p e t e n c e a n d the caring attitude o f the recovery r o o m n u r s i n g staff were often m e n t i o n e d as the reasons for s m o o t h p a t i e n t recovery f r o m anesthesia. We received no complaints o f p r e m a t u r e discharge f r o m the hospital. T h e patients whose p r o c e d u r e s were converted to o p e n cholecystectomy were i m m e d i a t e l y transf e r r e d to the i n p a t i e n t care u n i t at a nearby hospital via ambulance, where they stayed 1-2 days until they were able to eat a n d pain b e c a m e manageable with oral analgesic agents. Summary Elective laparoscopic cholecystectomy is p r e f e r a bly d o n e on an o u t p a t i e n t basis. Candidates for the p r o c e d u r e can be selected appropriately solely on the basis o f medical history a n d physical exami n a t i o n results. T h e p r o c e d u r e can be d o n e safely
OUTPATIENTLAPAROSCOPIC CHOLECYSTECTOIVlY 155 a n d can result in low morbidity, a high degree of patient satisfaction, a n d same-day discharge f r o m the hospital in > 95% of cases.
Acknowledgments We would like to t h a n k the staff o f H e a l t h South, Physicians Plaza Surgical Center, who assisted with the study, a n d the Medical Editing D e p a r t m e n t , Kaiser F o u n d a t i o n Research Institute, who provided editorial assistance.
References 1. Koo KP, and Traverso LW. Do preoperative indicatorspredict the presence of common bile duct stones during laparoscopic cholecystectomy?Am J Surg 1996;171:495-9. 2. Stain SC, Marsri LS, Froes ET, Sharma V, and Parekh D. Laparoscopic cholecystectomy:laboratorypredictors of choledocholithiasis. Am Surg 1994;60:767-71. 3. OlevskyD. Preemptive analgesiaallowssafe outpatient laparoscopic fundoplication [interviews]. Gen Surg Laparosc News 1996;17:1, 12. 4. Newman CL, Wilson RA, Newman L III, et al. 1525 laparoscopic cholecystectomieswithout biliary injury: a single institution's experience. Am Surg 1995;61:226-8. 5. RobinsonBL, DonohueJH, Gunes S, et al. Selectiveoperative cholangiography: appropriate management for laparoscopic cholecystectomy.Arch Surg 1995;130:625-31. 6. Soper NJ, and Dunnegan DL. Laparoscopic cholecystectomy: experience of a single surgeon. WorldJ Surg 1993;17:16-20. 7. RutledgeR, FakhrySM, Baker CC, and MeyerAA. The impact of laparoscopic cholecystectomyon the management and outcome of biliary tract disease in North Carolina: a statewide, population-based, time-series analysis.J Am Coll Surg 1996; 183:31-45. 8. Wherry DC, Marohn MR, Malanoski MP, Hetz SP, and Rich NM. An external audit of laparoscopic cholecystectomyin the steady state performed in medical treatment facilities of the Department of Defense. Ann Surg 1996;224:145-54.
outpatient p r o c e d u r e at an ambulatory Care dep a r t m e n t inside a hospital. We reviewed our experience with outpatient laparoscopic cholecystectomy d o n e 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 surgical center.
Study Design:We reviewed 213 cases in which outpatient laparoscopic cholecystectomy was d o n e at an ambulatory surgical center n o t associated w i t h a hospital physically or administratively. Patients were selected solely on the basis o f medical history and physical examinat i o n results. Patients received general anesthesia as is t y p i c a l for outpatient procedures. Narcotic use was m i n i m i z e d to prevent postoperative nausea. T h e procedure did not include intraoperative c h o l a n g i o g r a p h y .
The Ambulatory Surgical Center
The surgical center with which our medical group contracted is a corporation-owned, freestanding building n o t associated with any hospital physically or administratively. T h e nearest hospital is located ¾ miles away. Since May 1994, we have used the center to p e r f o r m laparoscopic cholecystectomy as an outpatient service (ie, patient remains in center -- 23 hours).
Results: Laparoscopic cholecystectomy took 1 to 2 hours
in three quarters of patients. Rate of conversion to o p e n cholecystectomy was 2.8% (6 of 213 patients). The mean recovery period was 6.6 hours, and 97% o f patients were discharged on the same day (ie, were treated as outpatients). We identified no cases of retained c o m m o n duct stone. Wound complications included mainly seroma, w o u n d seepage, and wound infection; 18% o f these complications were seen at trocar sites. N o major complications were seen.
Selection of Patients
O u r study included 213 patients who h a d undergone laparoscopic cholecystectomy between May 1994 and May 1996. In 211 patients, sonograms showed gallstones. O n e had an abnormal oral cholecystogram; 1 h a d cholecystectomy on the basis of typical biliary symptoms. No patient had a previous u p p e r abdominal operation. Selection criteria for outpatient laparoscopic cholecystectomy included history of symptomatic cholelithiasis or cholecystitis but no acute signs or symptoms when scheduled for elective outpatient surgery. Patients were admitted to the hospital if they had clinically significant pain, history of elevated leukocyte count, abnormal liver function test results (ordered selectively by referral sources), or clinically significant cardiopulmonary disease requiring specialized perioperative monitoring.
Conclusions: Elective outpatient laparoscopic cholecystectomy 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 b e c o m e a standard technique used in cholecystectomy, although inability to identify i m p o r t a n t anatomic structures necessitates intraoperative cholangiogram or conversion to an o p e n p r o c e d u r e for cholecystectomy. Use of laparoscopy in cholecystectomy can reduce surgery time and hospital stay. Consequently, most patients having laparoscopic cholecystectomy are discharged on t h e same day. Laparoscopic cholecystectomy is nevertheless usually still d o n e either as an inpatient p r o c e d u r e at a hospital or as an
Operative Techniques
Patients were anesthetized using propofol (Diprivan, Stuart Pharmaceuticals, Wilmington, DE), then orally intubated after adequate muscle relaxation was achieved. Anesthesia was m a i n t a i n e d using an inhalation agent (isofiurane), nitrous oxide, and a
Received December 2, 1996; Revised March 31, 1997; Accepted April 1, 1997. From the Department of Surgery, Kaiser Permanente Medical Ofrices, Bakersfield, CA. Correspondence address: David Lain, MD, Department of Surgery, Kaiser Permanente Medical Offices, PO Box 12099, Bakersfield, CA 93389-1299. © 1997 by the American College of Surgeons Published by Elsevier Science Inc.
1 52
ISSN 1072-7515/97/$17.00 PII S1072-7515 (97)00041-0
L a m e t al 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 Cholecystectomy* Cause
No. of patients
Severe gallbladder inflammation or gangrene Severe adhesion Spillage of large calculi Unclear anatomy
3 1 1 1
small dose of a narcotic agent. Parenteral ketorolac t r o m e t h a m i n e (Toradol, Syntex Laboratories, Inc, Humacao, PR) was given either before the p r o c e d u r e or about 15 minutes before its conclusion. T h e p r o c e d u r e was d o n e without intraoperative cholangiography. T h e 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. T h e c o m m o n bile duct itself c a n n o t always be seen, but continuity from the neck of the gallbladder to the cystic duct must be ascertained before clipping to prevent injury to a t e n t e d c o m m o n bile duct. No local anesthesia was given at trocar sites either preoperatively or postoperatively, and the peritoneal cavity was n o t irrigated with any anesthetic agent before closure. At arrival in the recovery room, most patients were given a laparoscopic cholecystectomy cocktail of m e t o c l o p r a m i d e hydrochloride (Reglan, A. H. Robins Company, Richmond, VA) and prochlorperazine (Compazine, SmithKline Beecham Pharmaceuticals, Philadelphia, PA). Nurses followed a standard postoperative protocol f o r additional m a n a g e m e n t .
e,
Q.
o '-
"-
E :3 z
153
T a b l e 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 S e r i e s 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 a n A m b u l a t o r y Surgical C e n t e r No. of complications
Type of complication
*Total number of patients who underwent laparoscopic cholecystectomy at ambulatory surgery center was 213.
.~
OUTPATIENT LAPAROSCOPIC CHOLECYSTECTOMY
Retained CBD calculi CBD injury Complications of w o u n d healing at trocar site Seroma Hematoma Infection Total
0* 0 17 1 20 38 (18%)
*Postoperative symptoms suggestive of biliary causes were evaluated by sonogram 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 o p e n cholecystectomy. Table 1 shows the causes of the conversions. For the 207 successful laparoscopic cholecystectomy procedures, operative time was < 1 h o u 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 a n d so can be considered outpatients. Length of stay in the recovery r o o m (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 effective as an outpatient p r o c e d u r e if patients are selected appropriately for the outpatient ap-
100 90 80 70 60 50 40 30 20 10 0 2h
4h
6h
8h
1Oh
12h
>12h
Length of stay (hr) FIG 1. L e n g t h o f stay in r e c o v e r y r o o m f o r p a t i e n 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 AUGUST1997
VOLUME185:152--155
proach and if the perioperative techniques used shorten postoperative recovery. The outpatient app r o a c h can be considered a practical and successful choice if rates of morbidity and conversion to o p e n p r o c e d u r e are comparable with those seen in the hospital setting, if the length of stay is appropriate for the outpatient setting, and if patients are satisfied with their care. We c o m p l e t e d 206 of 213 laparoscopic cholecystectomy cases on an outpatient basis. T h e other 7 cases included 6 conversions to o p e n cholecystectomy and 1 case of a patient with insulind 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 ultrasonography reports were usually attached to the medical charts. O n the basis of medical history, physical examination, a n d results of liver function tests (some d o n e at primary care offices), the patients who did n o t have cholecystitis or choledocholithiasis were selected for elective outpatient laparoscopic cholecystectomy. Only a routine complete blood cell count was d o n e preoperatively, and we did n o t cancel any cholecystectomy on the basis of hemogram results. Some patients had mildly dilated c o m m o n bile ducts (10 m m +__ 1 m m ) , but this condition did n o t preclude patients from elective outpatient laparoscopic cholecystectomy. Koo a n d Traverso (1) n o t e d a 12% prevalence rate for comm o n bile duct calculi in patients u n d e r g o i n g laparoscopic cholecystectomy and f o u n d that medical history (ie, of jaundice, pancreatitis, and known elevated results of liver function 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) f o u n d that elevated levels of alkaline phosphatase and a total bilirubin level higher than twice the normal level had a 55% positive predictive value for c o m m o n bile duct calculi. Liver function tests were obtained for any patient 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 patient was admitted to the hospital for preoperative endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Patients received the same general anesthesia as is routinely administered to patients having outpatient procedures. Emphasis was placed on shortacting, gaseous, a n d injectable anesthetic agents and minimal use of narcotic agents. Parenteral injection of ketorolac t r o m e t h a m i n e (Toradol) is increasingly being used for postanesthesia pain
control. Recent application of preemptive analgesic techniques such as injecting long-acting local anesthetic agents into trocar sites might further reduce postoperative pain a n d the resultant n e e d for postoperative stay along with associated narcotic use and nausea (3). In a patient series from Georgia Baptist Medical Center (4), selective intraoperative cholangiography was d o n e in 10.8% of patients to confirm presence of c o m m o n bile duct calculi a n d to delineate anatomy. We did n o t use intraoperative cholangiography but instead relied on o u r preoperative patient selection p r o c e d u r e and on clear identification of the cystic duct in relation to Hartm a n n ' s pouch. O u r series included no c o m m o n bile duct injury a n d no retained c o m m o n bile duct calculi as d e t e r m i n e d on the basis of longterm clinical outcome. The Mayo Clinic (5) r e p o r t e d a 0.6% incidence rate for retained c o m m o n bile duct calculi detected by using selective intraoperative cholangiography. A 0.2% incidence rate for retained c o m m o n bile duct calculi was reported by Soper and colleagues (6), who p e r f o r m e d selective intraoperative cholangiography in 30% of their patients. We followed u p our patients postoperatively until they had recovered completely from biliary problems. In one patient whose postoperative pain was evaluated by liver function tests and a gallbladder sonogram (which p r o d u c e d negative results), pain resolved spontaneously. In their series of 424 patients, Soper and colleagues (6) reported a 2.9% rate of m i n o r complications, a 1.5% rate of major complications, and one m i n o r injury to the c o m m o n bile duct. T h e Georgia group r e p o r t e d no bile duct injury in 1,525 patients and a 4% rate of major complications (4). O u r series of 213 patients included no c o m m o n bile duct injury, no major complications, and an 18% rate of m i n o r complications, most of which were related to w o u n d healing at trocar sites. T h e lack of major complications in o u r series derived from the restrictive selection criteria we used to d e t e r m i n e which patients were candidates for outpatient laparoscopic cholecystectomy. T h e patients selected for outpatient laparoscopic cholecystectomy had the simplest clinical history, normal physical examination 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 r o o m averaged 6.6 hours. In the Georgia series, 37% of patients were treated as outpatients, and m e a n length of hospital stay was .82 days (4). In a r e p o r t by Rutledge
L a m et al a n d colleagues (7), m e a n l e n g t h of hospital stay for elective laparoscopic cholecystectomy was 1.8 days. T h e Georgia g r o u p ' s 2.2% rate o f conversion to o p e n cholecystectomy (4) a n d Soper a n d Dunn e g a n ' s 1.9% incidence rate for conversion (6) are comparable with our 2.8% rate. W h e r r y a n d colleagues (8) listed three m a i n factors affecting risk o f conversion to o p e n cholecystectomy: choledocholithiasis, acute cholecystitis, a n d a b e r r a n t anatomy. In o u r series, all patients received a postoperative survey by mail. We received only positive comm e n t s f r o m o u t p a t i e n t laparoscopic cholecystect o m y patients. T h e c o m p e t e n c e a n d the caring attitude o f the recovery r o o m n u r s i n g staff were often m e n t i o n e d as the reasons for s m o o t h p a t i e n t recovery f r o m anesthesia. We received no complaints o f p r e m a t u r e discharge f r o m the hospital. T h e patients whose p r o c e d u r e s were converted to o p e n cholecystectomy were i m m e d i a t e l y transf e r r e d to the i n p a t i e n t care u n i t at a nearby hospital via ambulance, where they stayed 1-2 days until they were able to eat a n d pain b e c a m e manageable with oral analgesic agents. Summary Elective laparoscopic cholecystectomy is p r e f e r a bly d o n e on an o u t p a t i e n t basis. Candidates for the p r o c e d u r e can be selected appropriately solely on the basis o f medical history a n d physical exami n a t i o n results. T h e p r o c e d u r e can be d o n e safely
OUTPATIENTLAPAROSCOPIC CHOLECYSTECTOIVlY 155 a n d can result in low morbidity, a high degree of patient satisfaction, a n d same-day discharge f r o m the hospital in > 95% of cases.
Acknowledgments We would like to t h a n k the staff o f H e a l t h South, Physicians Plaza Surgical Center, who assisted with the study, a n d the Medical Editing D e p a r t m e n t , Kaiser F o u n d a t i o n Research Institute, who provided editorial assistance.
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