Day case Laparoscopic Cholecystectomy

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Day case Laparoscopic Cholecystectomy
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Introducing the Service

• Interested surgeon
• Money from CITEC
• Theatre team

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DSU Laparoscopic Protocol

• Patient Selection
• Consultant Surgeon selects in clinic
• Patients enthusiasm to undergo day case
• BMI under 35
• No history of post op nausea and
  vomiting(PONV)
• ASA grade 1
• Responsible carer for 24hrs post op
• Morning operating lists

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DSU Laparoscopic Protocol

• Pre operative
• Normal DSU assessment
• Bloods FBC, LFTs, U Es
• Fasting from 12 mid
• 1st on operating List
• 100mg PR Diclofenac (1 hour pre op)

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DSU Laparoscopic Protocol

• Peri-operative
• Anaesthetic protocol
• Consultant/experienced Laparoscopic
  surgeon/Anaesthetist/Theatre practitioner

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DSU Laparoscopic Protocol

• Post operative
• Nurse on Day Surgery Trolley
• ½ hourly B/P, pulse, temp, resps 2 hours
• Encourage mobilising after 2 hours
• Diet fluids progress to light diet
• Pain/nausea medication if required
• Discharge after 6pm

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DSU Laparoscopic Protocol

• Discharge
• Review by operating surgeon
• Minimal discomfort, no Pyrexia/PONV
• Cardio vascular stable
• Oral TTOs
• DSU contact for 48hours
• District Nurse visit following AM
• Telephone follow-up service following PM
  

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Day Case Anaesthetic Guidelines

• Laparoscopic Cholecystectomy

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Induction

• Dexamethasone 4mg (most effective if given
  pre-induction)
• Fentanyl 200 microg
• Propofol sleep dose
• Atracurium 0.5 mg/kg
• Paracetamol 1 g IV over 15 minutes
• Parecoxib 40 mg IV (if no Diclofenac)
• /- Atropine if that is your routine

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Airway

• ETT or LMA according to preference
• IPPV to normocapnia
• Nasogastric tube optional

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Maintenance

• Air/O2 and vapour choice

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Intra-op analgesia

• Further 50 microg boluses of fentanyl as dictated
  by rises in HR and/or BP
• Surgeon to infiltrate port sites with bupivacaine
  0.5

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Anti-emesis

• All patients should receive dexamethasone on
  induction
• All patients should receive 20 ml/kg fluid
  (fluid choice is yours)
• Further anti-emetics should be dictated by
  scoring system (eg Apfel)

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• Risk Factors Female
• Opioid use
• Non-smoker
• Previous history of PONV / Motion sickness
• For each additional two risk factors add in
  another one anti-emetic as per the published
  table at the bottom of the drug chart.
• Ondansetron is particularly good for stopping
  post-operative vomiting, if used as prophylaxis
  it is best given at the end of the case.

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Post-op analgesia

• Morphine 1mg boluses in PACU to 10mg
• Regular simple analgesia (remember to leave 6 hrs
  after the initial 1g of Paracetamol until the
  next oral dose)
• Codeine phosphate as per drug card

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Re-admission rate

• One patient was admitted during the 1st post
  operative night with excessive post op pain.
• One patient visited AE with haemoptysis and was
  diagnosed with a chest infection.

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Queries?

• advice given about wounds
• Asked whether needed to do breathing exercises,
  told to breathe as normal and keep mobilising
• Breathing - hurts to breathe due to upper wound
• District nurse did not attend - rang up but did
  not attend
• District Nurse had not been as yet. Reassured
  appointment made.
• Had phoned earlier to check how long ted
  stockings stayed on.
• seen by D/N today and asked when she could have
  fizzy drinks, after 48 hrs.
• She was advised to restart contraceptive pill
  after the next period.
• When to start contraceptive pill?
• Wondered about taking a bath taking dressings
  off.

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Suggestions or comments to help improve the DSU
service

• 15 x Happy with the service and the care provided
• Follow up care not happened as expected. Needs to
  be improved.
• Should make clear that no visitors allowed in
  DSU.
• Walking from PAAU in theatre gear
• When had bed pan no facilities to wash hands.
• Would not have recommended same day discharge.
  Would have liked to stay overnight as our beds
  are more comfortable! Seemed too much hassle to
  get dressed and go home.

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Where do we go from here!

• The protocol needs changing now consultation
  period is over.
• Pain medication given to take home needs to be
  assessed and if necessary revised.
• Service to be extended to all surgeons.
• Laparoscopic Cholecystectomy as day surgery needs
  to be considered the norm rather than the
  exception.