Page 19 - World Journal of Laparoscopic Surgery

Hindrance to Day Care Laparoscopic Cholecystectomy in India
the patients as day care but continued to monitor all the patients Table 1: Post-anesthesia discharge scoring system 4
till 24 hours to see whether any patients dischargeable at 6 hours Vital signs: Vital signs must be stable and consistent with age and
developed any complication during their stay which would have led preoperative baseline
to a readmission if at all they were discharged as day care. BP and pulse within 20% of preoperative baseline 2
BP and pulse 20–40% of preoperative baseline 1

MAterIAls And Methods BP and pulse 40% of preoperative baseline 0
This is a prospective observational study conducted in the Activity level: Patient must be able to ambulate at preoperative level
Department of General surgery at The Calcutta Medical Research Steady gait, no dizziness, or meets preoperative level 2
Institute, Kolkata, over a period of 6 months. All consecutive Requires assistance 1
patients, both male and female diagnosed with symptomatic Unable to ambulate 0
gallstone disease undergoing laparoscopic cholecystectomy in the Nausea and vomiting: The patient should have minimal nausea and
Department of General Surgery at The Calcutta Medical Research vomiting before discharge
Institute, who gave consent for being a part of the study were Minimal: Successfully treated with PO medication 2
included. Patients undergoing other combined procedures with
laparoscopic cholecystectomy and pregnant patients undergoing Moderate: Successfully treated with IM medication 1
laparoscopic cholecystectomy were excluded. Severe: Continues after repeated treatment 0
All patients who underwent laparoscopic cholecystectomy Pain: The patient should have minimal or no pain before discharge.
were evaluated preoperatively by a detailed history and the patient The level of pain that the patient has should be acceptable to the
factors such as age, sex, BMI, comorbid conditions, past history of patient. Pain should be controllable by oral analgesics. The location,
surgeries, and ASA score were noted. type, and intensity of pain should be consistent with anticipated
postoperative discomfort
Standard four-port laparoscopic cholecystectomy was
performed in all the patients by the consultant surgeon. If the Acceptability
gallbladder were not taken out through the umbilical port, the Yes 2
patient was excluded from the study. Standard institutional protocol No 1
for postoperative analgesia was followed for all patients. Surgical bleeding: Postoperative bleeding should be consistent with
Several scoring systems have been developed for discharge expected blood loss for the procedure
after ambulatory anesthesia, one of the most widely used being Minimal: Does not require dressing change 2
the post-anesthesia discharge scoring system (PADSS), introduced Moderate: Up to two dressing changes required 1
4
by Chung and colleagues in 1995. We assessed patients at 6 hours Severe: More than three dressing changes required 0
and 24 hours postoperatively using PADSS. Maximal score was 10. Maximum score = 10, score ≥9 is fit for discharge
Patients scoring 9 or 10 were fit for discharge (Table 1).
At 6 hours, the patients were assessed for their readiness for
discharge. All the patients continued to be monitored till 24 hours, 6 hours developed any complication during their period of stay in
any complication during this time was noted, and they were again the hospital and continued to remain dischargeable at 24 hours.
assessed at 24 hours for their readiness for discharge. If the patient Of all the variables analyzed, age, acute cholecystitis, diabetes
met the criteria for discharge at 24 hours, he/she was discharged mellitus (DM), hypertension (HTN), The American Society of
and if not discharged the reasons for delayed discharge were noted. Anesthesiologists (ASA) physical status classification system score,
The statistical software SPSS version 20 has been used for the difficulty, use of drain, and duration of surgery were found to have
analysis. All categorical variables were analyzed using Fischer exact significant association with dischargeability of the patients at 6
test and all continuous variables with Mann–Whitney test. An alpha hours (Table 2). After logistic regression, only acute cholecystitis
level of 5% has been taken, i.e., if any p value is less than 0.05, it has and duration of surgery had a significant association. From the ROC
been considered as significant. A multivariate logistic regression curve in our study, operating times more than 104 minutes can be
was performed including all variables with p value <0.05 to predict considered as a predictive factor for failure of DCLC.
the factors affecting discharge at 6 hours. Of all the factors accessed, difficulty of surgery and use of drain
were found to have significant association with dischargeability
of the patients at 24 hours (Table 3). As these factors were
result And AnAlysIs interdependent, we did not perform a regression analysis.

A total of 94 patients underwent laparoscopic cholecystectomy Of the total 88 patients analyzed, 78 (88.6%) patients
for symptomatic gallstone disease during the period of 6 months. dischargeable at 24 hours of which 60 patients were discharged
Six patients were excluded from the study, one patient due to at 24 hours. Rest of the 18 patients who were dischargeable were
conversion to open cholecystectomy and five patients as the not discharged because of various factors such as continuation of
gallbladder was removed from the epigastric port due to technical IV antibiotics (1), logistic insurance (6), patient factor (1), presence
difficulties. A total of 88 patients were included in the study. of drain (8), social factors such as patient living at a far distance (1),
Fifty-seven (64.7%) patients were dischargeable at 6 hours. At and surgeon anticipating complication (1) (Fig. 1).
24 hours, 21 more patients were dischargeable making a total of 78
(88.6%) patients dischargeable at 24 hours. Of the total 78 patients dIscussIon
dischargeable at 24 hours, 18 (23.08%) patients were not discharged The aim of our study was to detect the dischargeability of
due to various factors such as social factors, logistic factors, the laparoscopic cholecystectomy patients at 6 hours and 24
presence of drain, patient preference, and as surgeon anticipated hours and to determine the factors affecting discharge. As day
complications. None of the patients who were dischargeable at care laparoscopic cholecystectomy is not a routine practice

World Journal of Laparoscopic Surgery, Volume 13 Issue 1 (January–April 2020) 17