Day care laparoscopic surgery

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Our experience with day care laparoscopic surgery in a south indian setting

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Minimal access surgery as day-care Dr.Patta Radhakrishna MS, MCh , FAIS, FMAS. Head ,Surgical GE & Laparoscopic surgery SIMS Chennai, India.

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Chennai

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Day care laparoscopic Cholecystectomy in India Some still believe in open cholecystectomy Tremendous variation in hospital stay 2 – 4 night stay ;NPO for 2-3 days; drains Less than 24 hour stay – anecdotal Surgeons want to play safe Patients are not aware Insurance companies are ignorant

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Day care laparoscopic Cholecystectomy and us Initial reluctance from hospital authorities Stand-alone day surgery unit Dedicated team TAP block – absolutely pain free Progressive reduction in hospital stay Less than 6 hours Ultra-short stay laparoscopic cholecystectomy

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Ultra-short stay laparoscopic Cholecystectomy – pre-op Out patient consultation – symptomatic gall stones Pre-op investigation checklist Anesthetic evaluation Excluded patients with poor cardiac risk Uncontrolled hypothyroidism Severe coagulopathy Gangrenous cholecystitis Suspected carcinoma gall bladder

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Early morning scheduling Standard anesthetic protocol Bilateral Sub-costal and TAP block – pre-incision Supra-umbilical Verres needle Palmar point Standard 4 port technique Monopolar Maryland and hook Do not use Harmonic scalpel No drains Ultra-short stay laparoscopic Cholecystectomy – procedure

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General Anesthesia Induction with propofol / muscle relaxation with atracurium / orogastric tube/ Endotracheal intubation with appropriate sized cuffed tube/ IPPV / maintenance with oxygen/nitrous oxide/ desflurane Multimodal Analgesia -IV Fentanyl 1 – 2 µg /kg, IV Diclofenac 75 mg as infusion, if not contraindicated, IV Paracetamol 1 gm as infusion Multimodal antiemetic prophylaxis – IV dexamethasone 8mg at induction/ IV ondansetaron 4- 8 mg

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Bilateral Dual (BD) TAP Block 10 mm - Epigastric & Umbilical ports 5 mm - Right subcostal ports at mid- clavicular & anterior axillary line B/L Classical TAP + B/L Subcostal TAP 0.125% Bupivacaine – 20ml at each site Pre incision or Post surgery BD TAP block

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Bilateral Dual (BD) TAP Block Won the ‘best paper award’ at Annual conference of Indian Association of Ambulatory Surgery(IAAS) at Bangalore 2013

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Ultra-short stay laparoscopic Cholecystectomy – pt discharge Ryle’s tube at the time of surgery Oral liquids – 3 hours Closely monitored in the recovery ward Well trained recovery ward nurses Frequent visits by the anesthetist Maintenance of a pain score chart Nurse-mediated discharge 5 – 6 Hours After patient passes urine

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Ultra-short stay laparoscopic Cholecystectomy – pt discharge Patient walks to the ambulance Dropped at his / her hotel Light meal at night Normal breakfast - following morning Telephonic enquiry by a nurse at night Patient visits the surgeon in the morning Travel back home day after surgery Shower in the morning No skin sutures Oral analgesia or 3 days

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Ultra-short stay laparoscopic Cholecystectomy – statistics Period: Nov 2011 – Jan 2014 Total number of lap chole : 358 Acute cholecystitis – 32 Post – ERCP – 44 Completion cholecystectomy – 4 Completion chole in situs inversus totalis – 1 LC + hernia repair – 3 2 patients discharged with a drain

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Ultra-short stay laparoscopic Cholecystectomy – statistics Mean duration of surgery – 65 minutes Mean duration of hospital stay – 5.6 hours Time to oral liquids – 3.5 hours Time to ambulate - 3.6 hours Time to pass urine – 3.8 hours Pain score – 0-3 in 95% pts in 24 hours Significant POV - < 5%

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Ultra-short stay laparoscopic Cholecystectomy – hosp stay Pre-incision TAP block Post-incision TAP block

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Ultra-short stay laparoscopic Cholecystectomy – statistics Hospital re-admission rate - 0% Morbidity – 2/358 (0.5%) One patient – umbilical wound infection One patient – hematoma abdominal wall needing aspiration twice 30 day morbidity – 0.5%

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laparoscopic day surgery unit - other laparoscopic procedures Total no of other laparoscopic operations – 80 Lap groin hernia – 4 1 Lap ventral hernia – 10 Lap appendix – 3 Lap adhesiolysis – 10 Lap fundoplication – 4 Lap hydatid liver– 3 Lap rectopexy – 2 Lap others - 7 Mean hospital stay - 6 hours No hospital admission

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Ultra-short stay laparoscopic Cholecystectomy – summary Utra -short stay lap chole – feasible Proper selection of cases Pre-anesthetic check Patient education Standard anesthetic protocol Standard surgical technique Standard post-op regimen

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Ultra-short stay laparoscopic Cholecystectomy – summary Dedicated facility Committed nursing and para -medical team

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Bottom surgery as day-care Surgery for fissure-in- ano Surgery for hemorrhoids Surgery for fistula-in- ano Surgery for pilo-nidal sinus

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Dr.P.Radhakrishna Patta_radhakrishna@yahoo.co.in 09790924876

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