The learning curve in ambulatory laparoscopic cholecystectomy.

Whether laparoscopic cholecystectomy (LC) should be performed as an outpatient procedure is still under discussion. The aim of this study was to evaluate the influence of surgeon's experience in ambulatory management of LC. Three hundred eighty-one consecutive elective LCs were planned as outpatient procedures. An anesthetic protocol that includes free-opiates anesthesia, preemptive analgesia, and somatovisceral blockade was used. Percentages of ambulatory, overnight, and admitted patients were evaluated, and time series variation was also analyzed. Postoperative pain, nausea and vomiting incidence, postoperative recovery, and complications were examined. Two hundred ninety-one patients were strictly ambulatory (76.3%), 71 (18.6%) required overnight admission, and 19 (4.9%) were admitted. Percentage of ambulatory LC increased from 22% to 90% in 4 years of experience. Readmission rate was 0.01%. Free-opiates anesthetic techniques, preemptive analgesia, and somatovisceral blockade allowed us to obtain over 90% of ambulatory LC. The learning curve related to postoperative evaluation is crucial in obtaining those results.

[Intraoperative factors predictive of failure of the ambulatory regimen after laparoscopic cholecystectomy]. / Factores intraoperatorios predictivos del fracaso del régimen ambulatorio tras colecistectomía laparoscópica.

OBJECTIVES: To determine which intraoperative factors during ambulatory laparoscopic cholecystectomy predict postoperative admission. MATERIAL AND METHOD: Between January 1999 and August 2003, we attempted 410 consecutive laparoscopic cholecystectomies. Intraoperative variables were analyzed using univariate and multivariate methods. An intraoperative score was applied to determine the probability of successful ambulatory surgery in each patient. RESULTS: A total of 88.5% of the patients were strictly ambulatory. Forty-two patients required overnight admission, mostly due to social factors, and five patients required admission after 24-48 hours. Intraoperative variables predictive of postoperative admission were an operating time of more than 60 minutes (p = 0.011), gallbladder dissection with anatomic difficulty (p = 0.001), and cystic artery hemorrhage (p = 0.041). Surgical access to the abdominal cavity, gallbladder perforation, trocar wound or hepatic bed bleeding, intensity or grade of hemorrhage, and gallbladder extraction were not predictive variables. CONCLUSIONS: Ambulatory laparoscopic cholecystectomy is a safe and effective procedure. Operating time, correct dissection of gallbladder structures and hemorrhage of the gallbladder hilus, especially of the cystic artery, play a major role in the success or failure of ambulatory laparoscopic cholecystectomy.

Factores intraoperatorios predictivos del fracaso del régimen ambulatorio tras colecistectomía laparoscópica / Introsperative factors pedictive of failure of the ambulatory regimen after laparoscopic cholecysteroctomy

Objetivos. Establecer qué hechos intraoperatorios durante una colecistectomía laparoscópica con pretensión ambulatoria determinan su conversión en una operación con ingreso hospitalario. Material y método. Entre enero de 1999 y agosto de 2003 se realizaron 410 colecistectomías laparoscópicas consecutivas con pretensión de régimen ambulatorio. Se aplicaron análisis univariante y multivariante de variables intraoperatorias de los pacientes. Se aplicó un score intraoperatorio para determinar la probabilidad de régimen ambulatorio tras la colecistectomía laparoscópica en cada paciente. Resultados. El índice de sustitución de la serie global fue del 88,5%. Cuarenta y dos pacientes requirieron estancia nocturna en el hospital, la mayoría por causas sociales, y 5 precisaron ingreso después de 24-48 h. Los hechos intraoperatorios relacionados con el fracaso del pretendido régimen ambulatorio para la colecistectomía laparoscópica fueron el tiempo quirúrgico superior a 60 min (p = 0,011), la existencia de dificultad anatómica en la disección intraoperatoria de la vesícula biliar (p = 0,001) y la hemorragia de la arteria cística (p = 0,041). Variables como el acceso a la cavidad abdominal, la perforación vesicular, la hemorragia de las puertas de entrada o del lecho hepático, la intensidad o el grado de hemorragia, o la extracción vesicular no se comportaron como factores predictores. Conclusiones. La colecistectomía laparoscópica en régimen ambulatorio se puede realizar de manera segura y fiable. El tiempo operatorio, la correcta disección de estructuras hiliares y la hemorragia del hilio vesicular, especialmente de la arteria cística, desempeñan un papel importante en el éxito o el fracaso de la colecistectomía laparoscópica con pretensión ambulatoria (AU)

Objectives. To determine which intraoperative factors during ambulatory laparoscopic cholecystectomy predict postoperative admission. Material and method. Between January 1999 and August 2003, we attempted 410 consecutive laparoscopic cholecystectomies. Intraoperative variables were analyzed using univariate and multivariate methods. An intraoperative score was applied to determine the probability of successful ambulatory surgery in each patient. Results. A total of 88.5% of the patients were strictly ambulatory. Forty-two patients required overnight admission, mostly due to social factors, and five patients required admission after 24-48 hours. Intraoperative variables predictive of postoperative admission were an operating time of more than 60 minutes (p = 0.011), gallbladder dissection with anatomic difficulty (p = 0.001), and cystic artery hemorrhage (p = 0.041). Surgical access to the abdominal cavity, gallbladder perforation, trocar wound or hepatic bed bleeding, intensity or grade of hemorrhage, and gallbladder extraction were not predictive variables. Conclusions. Ambulatory laparoscopic cholecystectomy is a safe and effective procedure. Operating time, correct dissection of gallbladder structures and hemorrhage of the gallbladder hilus, especially of the cystic artery, play a major role in the success or failure of ambulatory laparoscopic cholecystectomy (AU)