This Handbook has been Updated by:
Mr David Bunting
Consultant Upper GI Surgeon North Devon District Hospital
Dr Kim Russon
Rotherham Foundation Trust Hospital
Contributors to Previous Edition:
Senior Lecturer and Consultant Anaesthetist
University Hospital of North Staffordshire
Consultant Surgeon, Milton Keynes
Consultant Anaesthetist, Chester
Day Surgery Ward Manager,
University Hospital of North Staffordshire
Consultant Upper Gastrointestinal Surgeon, University Hospital of North Staffordshire
Consultant Hepatobiliary Surgeon
Leeds and Hepatobiliary Lead for The Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS)
The laparoscopic approach for cholecystectomy gained widespread acceptance in the early 1990s and was the major factor allowing the procedure to be performed as a day case. It is now considered the preferred technique by most surgeons for most indications.
Day Case Rates
Day case rates have increased nationally over time from 16% in 2008/9  to a peak of 57% in 2016 . Since then rates have decreased slightly to 55% . The British Association of Day Surgery (BADS) Directory of Procedures 2016 suggests a target day case rate of 75%. There is still considerable variation in laparoscopic cholecystectomy day-case rates across the UK with some centres performing none as day case and others achieving rates consistently over 60%.
There have been a number of initiatives aimed at increasing day case rates, such as the NHS Institute for Innovation and Improvement’s ‘Focus on cholecystectomy: delivering quality and value’ guideline and the Rapid Improvement Programme through which it developed the ‘Transforming your day surgery services: focus on cholecystectomy’ toolkit .
There are a number of possible explanations for the day case rates not being consistently over 60% and why rates have fallen since the peak in 2016. Firstly, many National Health Service (NHS) Trusts are moving away from payment by results to block tariff contracts. The block contracts lack the financial incentive to discharge patients on the same day via the day case laparoscopic cholecystectomy best practice tariff. There has also been a move towards treating acute gallstone disease such as cholecystitis with early cholecystectomy. 2014 guidance from the National Institute for Health and Care Excellence (NICE) recommends offering laparoscopic cholecystectomy within one week of diagnosis to patients with acute cholecystitis. Whilst day case surgery can be undertaken for the ‘hot-gallbladder’, it is less easy to achieve, therefore, performing more early cholecystectomies can have the effect of reducing overall day case rates.
Factors Influencing Day Case Cholecystectomy
Since in many centres day case rates are consistently over 60%, it is often routine practice to adopt a default to day surgery policy unless there are any pre-existing absolute contraindications such as a patient who lives alone and is unable to arrange suitable care from family or friends.
Conversion to Open
A major factor influencing day case rates is conversion to open cholecystectomy which necessitates overnight admission. The large scale multi-centre CholeS audit identified a number of factors that were significantly associated with a higher risk of converting to open surgery. These included age (p= 0.005), sex (p < 0.001), indication for surgery (p < 0.001), ASA (p < 0.001), thick-walled gallbladder (p = 0.040) and common bile duct (CBD) diameter (p = 0.004).
The presence of these factors, however, should not preclude the laparoscopic approach since even a very high-risk score calculated using the CholeS criteria is associated with only 19% risk of conversion to open.
Previous upper abdominal surgery, although not recorded in the CholeS study, is also recognised to be a risk factor for conversion but should not preclude a laparoscopic approach. The technical approach should be adjusted in patients with previous upper abdominal surgery to enter the peritoneum with or without the use of an optical trocar away from any previous surgical scars.
Optical trocar entry can be achieved with or without the use of a Veress needle placed in the left upper quadrant, 3cm below the costal margin in the mid-clavicular line (Palmer’s point). A diagnostic laparoscopy can then be performed with adhesiolysis and attempted cholecystectomy if safe to do so.
There is a wide range of strategies available for management of choledocholithiasis (common bile duct stones). If cholecystectomy has been combined with exploration of the bile duct then most surgeons would choose to leave a drain in place and keep the patient overnight to monitor for the development of a bile leak. One exception perhaps would be in the case of trans-cystic duct approach in which the bile duct itself is not opened. If imaging suggests a clear duct then the risk of bile leak is low and the patient may safely be discharged on the same day. If the bile duct is not explored but intraoperative imaging with either cholangiogram or ultrasound suggests the presence of ductal stones then the surgeon will decide upon optimal further management. Small stones in the absence of jaundice may pass spontaneously. This presence of obstructive jaundice due to untreated choledocholithiasis is generally considered a contraindication to day case surgery due to the risks of bile leak and biliary sepsis.
The 'Hot' Gallbladder
There is no accepted definition of the ‘hot gallbladder’ although the term is generally used to refer to patients requiring admission to hospital with acute biliary pain or cholecystitis. Guidelines indicate that early laparoscopic cholecystectomy should be offered to patients presenting with acute cholecystitis within 1 week of diagnosis. The rationale for this is based on the fact that 25% patients awaiting interval cholecystectomy are re-admitted and that early cholecystectomy (within 5-7 days of an acute attack) is no more difficult or hazardous in experienced hands[8,9].
This guidance has led to an increase in the number of ‘hot gallbladder’ operations carried out, further increased by initiatives such as the Chole-QuIC project aimed at reducing time to urgent cholecystectomy for patients with acute biliary pain or cholecystitis and increasing the proportion of patients treated on an urgent basis by using quality improvement methodology. Patients undergoing urgent cholecystectomy suffer from sepsis and more pain than those operated on electively, which may be associated with a higher risk of unplanned overnight stay.
Other Operative Factors
There are a number of operative factors that are unpredictable and at the discretion of the surgeon, may warrant unplanned overnight stay. These include placement of drains, increased risk of post- operative haemorrhage and operative duration/difficulty.
Body Mass Index (BMI)
Obesity is no longer seen as an absolute contra-indication to day case surgery in expert hands with appropriate resources. The pneumoperitoneum can cause high ventilation pressures and if this causes problems with oxygenation then a frank discussion between anaesthetist and surgeon will need to occur regarding whether or not the operation should proceed.
Although patients with a high BMI are at increased risk of surgical complications, day case surgery in this group has been shown to be safe and has significant advantages in relation to cost and patient satisfaction. A recent study has shown no association between BMI and rates of day case discharge, intra-abdominal collection or re-admission. Even in patients with BMI>40, day case rates of over 75% and 85% have be consistently achieved. Increasing BMI is associated with longer operating times and more wound infections; although these should not be used as rationale for over-night stay.
As with obesity, the majority of co-morbidities predict intraoperative, rather than postoperative, complications. Day case laparoscopic cholecystectomy can be performed safely in patients with a wide range of co-existing conditions, provided that these are stable and optimally managed. The creation of a pneumoperitoneum may have adverse consequences for those with severe cardiovascular or respiratory diseases and make laparoscopic surgery not a suitable option. An increased likelihood of postoperative nausea should be managed actively. Diabetes need not be a contraindication to day surgery if these patients are managed well and delaying oral intake can be reduced to no more than one missed meal .
Patients’ and relatives’ attitudes towards day case surgery are very important in determining success of day case surgery. A willingness to engage in the day case process is helped by provision of appropriate pre-operative information and counselling, reducing anxiety and increasing co- operation. This is important at each step of the pathway including GP referral, outpatient appointments, pre-operative assessment and the day of admission. Consistency of information is vital whether it is communicated in person, or through patient information leaflets, DVDs and trust websites.
Default to Day Surgery
Peri-operative problems which can prevent same day discharge are difficult to predict and the best strategy is to manage most patients as intended day cases, with subsequent admission arranged if necessary. Exceptions to this rule include any absolute contraindication to day surgery, such as a patient who lives alone and is unable to arrange suitable care from friends or family. There may be specific operative factors, such as a planned common bile duct exploration via choledochotomy (opening the bile duct directly) which most surgeons consider requires placement of a drain and overnight admission.
Factors discussed above that may lead to a higher rate of unplanned overnight stay can be utilised in list scheduling, so that patients with potential problems are scheduled early to allow a longer recovery period and a greater likelihood of same-day discharge. Cases considered to be straightforward can be operated on later in the day.
A default to day surgery approach allows more consistent patient information and preparation and also ensures that all patients receive the same quality of anaesthesia and pain relief. Treating all, unselected, patients as potential day cases can achieve extremely high rates of successful same day discharge.
Pre-operative assessment for the patient awaiting laparoscopic cholecystectomy aims to help achieve high quality care, to facilitate same-day discharge, to minimise re-admission rates and to help reduce complication rates through identifying and managing co-morbidity. Integrated care pathways are now used widely and help in standardising patient management. Specific attention should be given to the following areas in patients undergoing laparoscopic cholecystectomy:
Recent and prolonged attacks of right-upper quadrant pain may indicate the development of cholecystitis. This information can be useful in predicting operative time and may be an indication to schedule early on the operating list.
Important diagnostic investigations such as liver function tests and ultrasound scan should have been performed prior to waiting list booking. Liver function tests are useful in screening for passage of gallstones into the bile duct. These should be performed within 3 months of surgery; however, they should also be repeated if the patient develops any symptoms of obstructive jaundice.
Individual surgeons will have their own preferences for managing patients with abnormal LFTs. Blood tests such as full blood count, coagulation screen and urea & electrolytes are now not performed routinely in most units, rather they are undertaken selectively in patients per NICE guidance.
For many years, routine group & save (G&S) was considered mandatory for laparoscopic cholecystectomy, however, severe peri-operative haemorrhage is rare. For this reason, some authors now suggest that following a G&S taken at pre-operative assessment to screen for atypical antibodies and establish ABO/Rhesus blood group, a second G&S on the day of surgery for electronic-matching is not necessary. Recent reports have suggested that routine G&S is not required at all [17, 18]. In most cases of peri-operative haemorrhage, there is time to arrange formal cross-matching and in the rare event of major haemorrhage, ‘emergency’ group O blood can be administered. Therefore, in order to reduce the costs of G&S which in an era of electronic cross-matching, mandates two separate samples, many trusts no longer routinely undertake G&S in their patients undergoing elective laparoscopic cholecystectomy.
Verbal advice should start in the surgeon’s clinic when the patient is informed they need surgery and when they are added to the waiting list. The consent process is started at this stage and should involve general details of what to expect including the nature of day case surgery and recovery in addition to the risks and benefits of the surgery itself. Recommended practice is to provide written information in the form of a patient information leaflet to supplement verbal advice. Some Trusts also provide a patient information DVD, or link to where information videos can be found on the trust websites.
The observation that surgery in obese patients can be technically more challenging and longer has prompted many surgeons to advise obese patients to adhere to a low-calorie diet for a specific period of time prior to surgery. Specifically, this is thought to make surgery easier by reducing the weight and stiffness of the liver, aiding retraction and reducing bleeding and by increasing abdominal wall compliance, thereby increasing the volume of the pneumoperitoneum. Whilst these latter factors have not been proven, a randomised study has shown significantly greater pre- operative weight loss, shorter operative time and subjectively easier Calot’s triangle dissection in patients adhering to a two-week very low-calorie diet compared to patients following a normal diet. It is now routine practice in many units to advice patients to follow such a diet for two weeks preoperatively.
As with any day case procedure, laparoscopic cholecystectomy requires an anaesthetic technique which provides for a rapid recovery and minimises the incidence of side effects. In addition, particular consideration needs to be given to prevention and treatment of postoperative nausea and vomiting (PONV) and pain management.
Pre-operative assessment and explanation of anaesthesia by the anaesthetist and what to expect postoperatively in terms of pain and sickness will occur on the day of surgery for the majority of patients. Excessive starvation should be avoided and pre-operative analgesic and anti-emetic premedication are recommended.
Experienced day surgery anaesthetists tend to achieve lower rates of postoperative complications and hospital admissions than non-specialists, although the use of anaesthetic protocols (or “guidelines”) can help transfer some of this experience to the occasional day surgery anaesthetist.
Choice of Anaesthetic Agent
Many anaesthetists advocate propofol-based techniques, due to their beneficial reduction of PONV, but others achieve good results with volatile anaesthetics. Using a technique with which the anaesthetist is familiar and which is known to achieve good outcomes is probably more important than the specific choice of agent. Remifentanil has increased in popularity and most anaesthetists choose to avoid nitrous oxide. However, omitting nitrous oxide does not reliably reduce the occurrence of PONV after laparoscopic cholecystectomy; neither does it improve surgical conditions.
The consensus guidelines for the management of postoperative nausea and vomiting 2014 has suggested avoiding nitrous oxide and volatiles to reduce baseline risk of PONV.
Controversy remains over the use of the laryngeal mask airway (LMA) for laparoscopic cholecystectomy. While the LMA is widely used in many forms of day surgery, there is justifiable concern that reflux of gastric contents and bile, which is especially irritant, may be more common during gall bladder surgery. At least one case of aspiration during cholecystectomy with the LMA has been reported. The Proseal® LMA offers increased protection from aspiration and provides increased seal pressure and easier controlled ventilation compared to the conventional LMA during laparoscopic cholecystectomy. There is still insufficient published evidence on which to judge its safety for this procedure, but some anaesthetists have used it extensively without apparent problems.
Post-Operative Nauseas and Vomiting
PONV is common after laparoscopic cholecystectomy, possibly because of peritoneal gas insufflation, bowel and biliary tree manipulation. Additional risk factors include female gender, previous history of PONV or motion sickness, being a non-smoker and the use of perioperative opioids. The latter are a common cause of PONV and their use, even during laparoscopic cholecystectomy, should be reduced to the minimum necessary. The effect of drugs used to reverse neuromuscular block on PONV is controversial, but it seems sensible to avoid them if spontaneous recovery of neuromuscular function is sufficient.
The consensus guidelines for the management of postoperative nausea and vomiting 2014 has suggested avoiding nitrous oxide and volatiles to reduce baseline risk, ensure adequate hydration and minimization of intraoperative and postoperative opioids.
PONV is sufficiently common after laparoscopic cholecystectomy, that antiemetic prophylaxis with a combination of agents is justified. These should be effective and relatively free from adverse effects. Ondansetron (or other 5HT3 antagonists) and dexamethasone are suitable. The latter is long lasting and may also provide a degree of analgesia but should be avoided in patients with diabetes due to risk of hyperglycaemia. Adequate hydration, with at least one litre of intravenous fluid during the procedure is an important additional measure to reduce PONV. Some centres have found Acupins of use in reducing their PONV rate.
PONV should be promptly treated when it occurs, preferably using an antiemetic of a different class to that used for prophylaxis. Further rehydration may be necessary. Intractable PONV is not an automatic indication for hospital admission, provided that the patient is able to retain some fluids and is still happy to be discharged. Consideration should be given to take-home antiemetic therapy. Buccal, sublingual or subcutaneous routes of administration are preferable in this instance, as they will ensure adequate drug absorption even in the presence of nausea. PONV is most common in the immediate recovery period, sometimes persists for one to two days, but usually resolves thereafter. However, a very small minority of patients experience severe PONV for many days after laparoscopic cholecystectomy.
Effective pain relief should be provided using a multimodal approach which aims to minimise or avoid the use of strong opioids, thereby limiting side effects and reducing pain and PONV. This should be started pre-operatively.
Non-Steroidal Anti-Inflammatory Drugs (NAAIDs)
NSAIDs are extremely effective analgesics and should be used unless there is an absolute contraindication. Ibuprofen and diclofenac are well-established and have a reasonable safety profile, particularly when only given for short courses. The oral route is preferred to rectal or parenteral administration . There is no consensus on when the first dose should be given.
NSAIDs should be administered at regular intervals and the patient should be given a supply sufficient to last at least five days to take home. NSAIDs with a long half-life or sustained release preparations, which permit once-daily dosing, may be more convenient.
Paracetamol and Codeine Compounds
Paracetamol and paracetamol-codeine combinations can be used to supplement the analgesia provided by NSAIDs. They appear to have an additive effect as analgesics but have a different side- effect profile and so do not substantially increase risk. These drugs may also be used as first-line analgesia where NSAIDs are contraindicated. Opiate medication can cause increased tone in the Sphincter of Oddi. For this reason, it has been suggested that patients with suspected or known CBD stones should avoid these medications as they could exacerbate any resulting symptoms. An oral dose of paracetamol can be given pre-operatively or alternatively an intravenous dose near the end of the procedure.
A take-home supply should again be provided for several days. Many units now prefer to issue paracetamol separately to codeine rather than the combination preparations to avoid accidental paracetamol overdosing and to minimise complications (such as constipation) associated with the regular use of opioids.
Although much of the postoperative pain is deep in nature, the laparoscopy portals should always be infiltrated with a long acting local anaesthetic (such as bupivacaine or levobupivacaine). 0.5% solutions should be used at a maximum total dose of 2 mg/kg (20 ml will be safe and effective in the majority of adults). This may be administered before skin incision or at the end of the procedure.
The results of intraperitoneal local anaesthetic, sprayed between liver and diaphragm, have been variable in efficacy, although a recent meta-analysis suggested there was an overall small reduction in pain scores with this technique. Other techniques, such as transversus abdominis plane (TAP) block, or even intrapleural analgesia may be effective, but it is doubtful if the time taken to complete these blocks, and their potential adverse effects, are justified for this procedure.
In the previous edition of this booklet the routine use of intraoperative opioids was discouraged until the early postoperative period and the use of a strong opioid may be needed to treat acute pain in the early postoperative period. This allows the dose to be carefully titrated so as to provide adequate analgesia whilst minimising side effects, such as nausea, respiratory depression and sedation. Fentanyl is ideal in this respect, being both rapid and short-acting.
Many centres successfully use morphine intra-operatively but centres with higher day-care rates (see Appendix) appear to be using fentanyl 200-300mcg.
Systemic opioids should not be required beyond the first few hours of recovery, when oral analgesics are usually sufficient.
Historically, pethidine was said to be the opioid of choice for biliary surgery, due to its anti- spasmodic effects. In practice, any apparent benefits were attributable to a lower relative dose being administered.
Natural History of Pain
Pain is common after laparoscopic cholecystectomy, despite the use of prophylactic, multimodal analgesia, but the incidence is variable and difficult to predict, bearing little relationship to intraoperative surgical findings or haemodynamic response. Many patients are likely to require some opioid “rescue” analgesia during early recovery and/or one or two doses of oral analgesia prior to discharge. Pain tends to be moderately severe during the first one or two days, declining rapidly in intensity beyond that. A few patients experience prolonged and severe pain, but this is not common. Severe pain may prevent discharge on the day of surgery, but this should be an unusual event with appropriate therapy.
Routine laparoscopic cholecystectomy should take under an hour in most cases but, with modern anaesthetic techniques, same-day discharge is still possible after considerably longer procedures, provided there is adequate postoperative recovery time before the day unit closes.
The most common approach uses a 4-port technique with a sub-umbilical 10-12mm diameter port, a 10-12mm epigastric port and two 5mm right upper quadrant ports. There are a number of variations in this technique, some only using 3 ports, some using 3mm ports or needlescopic instruments (directly traversing the abdominal wall without the use of a port/cannula) instead of 5mm ports and others adopting the use of 5mm cameras. However, there is no good evidence to support the use of any single technique over another. Single-incision surgery), natural orifice transluminal endoscopic surgery (NOTES) and robotic surgery have all been undertaken successfully as day case procedures, however, none have been adopted widely in the UK. In particular, an analysis of surgical value defined by outcome divided by cost suggested that single incision surgery and robotic surgery offered significantly less value than traditional 4-port cholecystectomy, therefore, neither are likely to become commonplace in the UK.
Access to the peritoneum is frequently established by open cut-down immediately below or above the umbilicus, however, other techniques are often used such as optical trocar entry with or without prior Veress needle insufflation.
A standard operating pressure of up to 12mmHg to maintain the carbon dioxide (CO2) pneumoperitoneum is normally used to avoid inferior vena cava compression/reduced venous return and to prevent diaphragmatic splinting, otherwise resulting in lower ventilatory tidal volumes and the need for higher airway pressures. Abdominal pain and shoulder tip pain are both significantly associated with the volume of residual pneumoperitoneum, so efforts should be made to release as much gas as possible before closure.
Free blood or bile in the peritoneum can give rise to post-operative pain; so, any spilled bile or blood should be irrigated and suctioned and careful attention should be made to ensure haemostasis, for example in the liver bed. The use of local anaesthetic is described above.
Wound drains are sometimes left to drain any residual wash fluid or carbon dioxide gas and, in some cases, when it is felt there is increased risk of bile leakage or bleeding. This is usually a matter of individual surgeon choice; however, the routine use of drains should be avoided since their presence and removal can be associated with unnecessary pain. Drains may be removed on the day of surgery according to surgeon’s preference and indication and are, therefore, not a barrier to day case discharge.
All of the usual day surgery discharge criteria apply to patients undergoing laparoscopic cholecystectomy, however, as the patient has had an intra-abdominal procedure, albeit by minimally invasive surgery, then it is more important than usual to ensure that the patient can tolerate oral fluids and a light diet.
Fitness for discharge should be based on defined parameters, rather than time-based. In practice, most patients will take 4–6 hours to achieve the discharge criteria. Successful discharge should be possible after operations performed in the morning or afternoon but this is naturally dependent on the discharge criteria and critically, what time the day surgery unit stays open until. If patients are transferred to an inpatient ward, they are much less likely to be discharged on the same day.
Patients should be discharged with written advice highlighting the signs that could indicate complications requiring urgent medical attention.
- Laparoscopic cholecystectomy day case rates of over 60% can be achieved consistently, by adopting a default to day surgery policy.
- NICE recommends early laparoscopic cholecystectomy for patients presenting with acute cholecystitis within 1 week of This guidance has led to an increase in the number of ‘hot gallbladder’ operations carried out.
- Patients’ and relatives’ attitudes towards day case surgery are very important in determining success of day case surgery.
- Integrated care pathways are now used widely and help in standardising patient management.
- The routine use of drains should be avoided though it is not a barrier to day case discharge.
- Analgesia should be multi-modal and pre-emptive treatment should be given for analgesia and anti-emesis.
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- Discuss post-operative analgesia with patient, stress that paracetamol if given in isolation is to be taken regularly for 48 hours post op regardless of pain.
- Ibuprofen slow release 1600mg orally
- Paracetamol 1g orally
- Fentanyl as required, normally 200 – 300 mcg
- Prophylactic antiemetics, dexamethasone and cyclizine or metoclopramide
- IV fluid – 1000ml Hartmanns
- Local infiltration to port sites by surgeon
- Fentanyl IV 25mcg boluses to control pain
- Treatment of any PONV, further fluids & Metoclopramide/cyclizine +/-Ondansetron
- Prescribe TTA’s – Ibuprofen 400mg four times daily
- Co-codamol 30/500 PO QDS
- Laxido 1 sachet orally twice daily
- May need to change prescription to Oramorph and Paracetamol.
- Regular paracetamol
- 1st line PO analgesic Oramorph 20mg
- Treat any PONV aggressively