Introduction

Since the introduction of laparoscopic surgery in the late 1980s and early 1990s, it has soon become the standard treatment for a variety of diseases. In recent studies, some of the laparoscopic procedures have been evaluated as a safe and effective outpatient procedure.1,2 In Hong Kong, we have been practising outpatient laparoscopic cholecystectomy (LC) and outpatient endoscopic totally extraperitoneal inguinal hernioplasty (TEP) since 2000 and 2001, respectively.2-4 Now they have become our standard treatments for selected patients with symptomatic gallstone diseases and groin hernias. Unlike other western countries, advocating outpatient procedures in Hong Kong is not cost-driven but patient-driven. Patients in Hong Kong have a drive to receive a high standard of surgical service and alternative treatments for surgical diseases.

Outpatient Laparoscopic Cholecystectomy (LC)

Since 2000, we have been routinely performing outpatient LC in selected groups of patients with symptomatic gallstone diseases. Patients of American Society of Anaesthesiologists (ASA) risk classification I or II, less than 70 years of age, as well as accompanied and looked after by a competent adult for at least twenty-four hours post-operation were included. No attempt was made to avoid difficult cases. All patients were recruited during the initial outpatient follow-up and the full perioperative details were explained. They would be given the date of operation and written instructions concerning the preparation, admission and highlights of procedures. Patients were admitted at 7:30 am on the day of operation.

Outpatient LC was defined as operations performed on patients who could be discharged before 6:00 pm on the day of operation. We adopted the standard four-port technique using 12 mmHg of CO2 pneumoperitoneum, and intraoperative cholangiography was not routinely used. Gastric tube and Foley catheter were not used. More than 95% of the patients were operated by two experienced specialist surgeons (YWK, LH) and the remaining 5% of the cases were performed by higher surgical trainees under supervision. Patients were then transferred to Day Surgery Centre for close observation.

Results

In 2000, the successful outpatient LC rate was only 72.7%, among which 8% was overnight stay and the conversion rate was 9.1%.4 The successful rate gradually increased to 100% in 2004 (Table 1) and no conversion was noted. The incidence of postoperative nausea and vomiting was low. Pain control was also excellent. So far there have been no major complications encountered except mild wound infections. Nearly all patients returned to their preoperative activities-of-daily-living by two weeks.

table 1

Pre-anaesthetic clinic (PAC)

The establishment of PAC was a major milestone in the development of outpatient LC. It allowed early assessment by the anaesthesiologist, preoperative counselling by nursing staff and routine investigations before operation. It has been shown that PAC significantly reduced patients’ anxiety,5 contributing to a potential favourable impact on outcomes. As in the earlier phase of outpatient LC, the overnight stay rate was 8% and almost all of the patients stayed overnight due to psychosocial reasons.2

Day Surgery Centre (DSC)

Another milestone for outpatient LC was the establishment of DSC. It provided a place for patients to relax before operation and for close observation after operation. Nursing staffs were trained for early recognition of potential complications. In addition to clinical observation, patients were considered eligible for discharge when they fulfilled a set of pre-discharge criteria (Table 2). A 24-hour hotline was provided before discharge. A dedicated nursing staff would perform phone questionnaire on postoperative days one and three. The operating surgeon would follow all the patients at DSC at postoperative weeks one and four.

table 2

Standard anaesthetic protocol and postoperative pain management

Postoperative nausea and vomiting was a common problem leading to failure in outpatient laparoscopic procedures. We adopted a standard anaesthetic protocol in performing the operations. Anaesthesia was induced using intravenous propofol and fentanyl at the body-mass-dependent dose. Following an endotracheal intubation, all patients were put on mechanical ventilation and on inhalational anaesthetic agents (nitric oxide and isoflurane) for maintenance. Before reversal of the anaesthesia, all of them would be given intravenous metoclopramide as the anti-emetics. Another dose of metoclopramide or ondansetron would be given when necessary after the procedure if they developed repeated vomiting. Opiate- free anaesthetic protocol, involvement of an experienced anaesthesiologist and good communication between the anaesthesiologist and the operating surgeon (so as to reduce inhalational anaesthetic gas at the end of operation earlier) would be the keys to the avoidance of postoperative nausea and vomiting.

At the end of the operation, all port-sites would be infiltrated with 2-3 ml of 0.25% bupivacaine. After the operation, all patients were given adequate oral paracetamol 1 tablet every 6 hours and diclofenac 100 mg tablet daily when necessary. Pain control based on the above regimen was excellent.3-4

Outpatient Endoscopic Totally Extraperitoneal Inguinal Hernioplasty (TEP)

TEP was first performed in 1999 at our institution. With an experience of 200 in-patient TEPs, outpatient TEP has been performed since 2001. Between March 2001 and 2003, patients who underwent outpatient TEP by a single surgeon (HL) at our department were recruited. Inclusion criteria were reducibility of the inguinal hernia, ASA risk classification of I or II, as well as the presence of a competent adult to accompany the patient home and look after the patient for 24 hours. In addition, patients had to live within one hour’s travel to the hospital. Previous lower abdominal surgery was considered a contraindication for TEP.

All patients were admitted to DSC on the day of operation. Pre-emptive ketorolac 30 mg was administered intravenously upon induction of general anaesthesia. The standard anaesthetic protocol and the anaesthetic team were the same as described in outpatient LC. The operative details were described elsewhere.6 A three-port technique was employed. Balloon dissection and urinary catheter were not utilized. The extraperitoneal space was dissected and created using endoscissors with diathermy. A Prolene mesh of 10 x 14 cm2 was placed to cover the deep inguinal ring, the posterior wall of the inguinal canal, and the femoral ring. Wounds were infiltrated with 0.5% bupivacaine as in outpatient LC.

Results

A total of 417 patients underwent TEP during the study period. One hundred and two patients (24.5%) with 114 inguinal hernias, who underwent TEP as an outpatient procedure, were recruited. All TEPs were successfully performed. None of the patients required conversion. The successful rate was 97%. Three patients were admitted overnight because of ECG changes during surgery and dizziness. One patient required readmission to hospital on postoperative day one because of wound pain and vomiting. Overall, the rate of postoperative nausea and vomiting was very low. Only mild postoperative complications such as: seroma and bruising, were encountered, but they were all self-limiting. No recurrence was noted at a mean follow-up of 5 months.2

The important roles of DSC, a standardized anaesthetic protocol and postoperative pain management as well as the PAC have been previously discussed. In addition, a randomized trial was conducted to compare the outcome of outpatient TEP with outpatient open Lichtenstein hernioplasty.

Comparison with outpatient Lichtenstein hernioplasty in male patients

From 2002 to 2004, a total of 200 male patients were randomized to undergo either outpatient unilateral TEP or open Lichtenstein hernioplasty under general anaesthesia. All TEP were successfully performed without conversion. The mean operation time for TEP (50 ± 13.2 min) was significantly shorter than that for open repair (58 ± 17.6 min) (P < 0.001). The pain score at rest was significantly lower in the TEP group than in the open group. On average, the patients returned to work 8.6 days after TEP and 14 days after Lichtenstein hernioplasty (P = 0.006). The incidence of chronic groin pain 1 year after TEP (9.9 %) was significantly lower than that after open surgery (21.7%) (P = 0.032).

In conclusion, outpatient TEP was superior to open Lichtenstein hernioplasty for repair of primary inguinal hernia in male patients. The benefits of outpatient TEP included less pain, a faster return to work, and a lower incidence of chronic groin pain.7

Future Directions

Despite the early success in outpatient LC, striving for a higher standard of patient care is still the ultimate goal for surgeons. Recently, a randomized trial was conducted at our department to compare low-pressure (7 mmHg) versus standard-pressure pneumoperitoneum (12 mmHg) in outpatient LC. It was shown that for simple and uncomplicated gallstone diseases, low-pressure pneumoperitoneum was safe and effective with similar outcomes when compared with diseases treated under standard-pressure pneumoperitoneum.8

It is not uncommon for patients with groin hernias to have significant co-morbidities, which are considered a relative contra-indication for TEP because it needs to be performed under general anaesthesia. The early result of these patients undergoing TEP under spinal anaesthesia was released from our department. Four patients successfully underwent TEP under spinal anaesthesia. Two patients required conversion to open repair because of lack of cooperation and inadequate spinal anaesthesia. No significant complication was encountered. To shorten the operation time, an experienced laparoscopic surgeon was the pre-requisite for a successful procedure. Nonetheless, good cooperation among the anaesthesiologist, surgeon and patient cannot be overlooked.9 It provided an alternative choice other than open repair for patients with significant co-morbidities.

Discussion

Our results showed that most patients undergoing laparoscopic surgery had a high level of satisfaction.3 Less than 3% of the patients refused an outpatient LC if they were to be treated again, reflecting that patient acceptance was high.3 Opponents against outpatient laparoscopic surgery, probably is because of its potential complications, and more importantly, delayed diagnosis due to early discharge. Previous studies showed that most postoperative complications related to LC such as bile leakage, retained ductal stones and biliary pancreatitis were not apparent on the first 2 days of postoperation.11-13 After patients were discharged from the hospital, the nursing staff in DSC would perform telephone follow-up on postoperative days 1 and 3. Possible complications such as abnormal discharge from wound, unusual degree of wound or abdominal pain and fever would be noted. After initial assessment on the phone, patients would be arranged to have a follow-up by the operating surgeon at their earliest convenience. So far, no major complications have been encountered.

There is still much room for developing other outpatient procedures as well as refining the techniques of the present procedures. Reports showed that laparoscopic anti-reflux surgery, laparoscopic adrena-lectomy and laparoscopic splenectomy were all feasible in an outpatient setting.10 Different laparoscopic procedures, however, would have different learning curves. As illustrated in our experience, when the majority of patients were operated by experienced laparoscopic surgeons, the training for surgical trainees might be hampered. A recent study showed that outpatient LC could be performed safely by surgical trainees under direct supervision.14 We were in the same situation and hopefully, trainees could do more outpatient laparoscopic procedures in the future.

The training of laparoscopic surgeons should ideally start with the relatively “easy-mastered” outpatient procedure, such as LC before embarking on other more advanced techniques. Apart from the surgeons’ perspective, other associated “hard and soft wares” such as the establishment of the DSC, availability of well-trained nursing and anaesthetic staff, etc, should be ready before the commencement of outpatient laparoscopic surgery. It would be disastrous if potential complications are overlooked.

Without great courage, successful outpatient laparoscopic surgery would not be possible.

Abbreviations

Laparoscopic cholecystectomy: LC; Endoscopic totally extraperitoneal inguinal hernioplasty: TEP; Day Surgery Centre: DSC; Pre-anaesthetic clinic: PAC.

References

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#Printed with the permission of the Editor, Day Surgery Journal of India.
*Department of Surgery, The University of Hong Kong, Queen Mary and Tung Wah Hospitals, Hong Kong, China.