Dr Prakash Agarwal Dr R.K.Bagdi Apollo Children’s Hospital, Chennai.

 Laparoscopic cholecystectomy (LC) as first line treatment for symptomatic cholelithiasis is well established.  Introduction of day-case LC (DCLC) in adults since 1990s in Pediatrics since  DCLC is now listed on the British Association of Day Surgery  India: Day case surgical association.

 Clinical outcomes of Paediatric laparoscopic Cholecystectomy in day care  Cost-effectiveness  The primary consideration however should remain patient safety

“A recent meta-analysis of five randomized controlled trials in adults demonstrated that compared with overnight stay, DCLC is safe and effective in selected patients and is likely to save costs”

INCLUSION CRITERIA - ASA Gr I & II - Staying close to Hosp - Willing to return to hosp in case of problem - Parents able to understand the instructions well EXCLUSION CRITERIA - Co-morbid conditions - Raised LFT - Staying far from the hospital - Insurance company not agreeing for Day care surgery - If a second surgery is planned The role of DCLC in pediatric practice is yet to be established. There has been only two reports on DCLC in children

Referral of children with symptomatic cholelithiasis to outpatients clinic History and examination & Informed consent for laparoscopic cholecystectomy Outpatient CBC, U&Es, LFTs and abdominal ultrasound scan Inclusion criteria for DCLC met-DCLC scheduled Inclusion criteria for DCLC not met- DCLC not appropriate Admission on morning of procedure and LC on morning list Anaesthetic/Analgesia protocol PONV prophylaxis and management Nursing Protocol

Data relating to the cases were collected prospectively and clinical outcomes were audited All patients were seen in the outpatient clinic before DCLC Informed consent was obtained. Blood tests and an abdominal ultrasound scan were requested. Patients were admitted electively on the morning of the procedure and Underwent a LC on the morning list.

ANESTHESIASURGERY  Induction of anesthesia was with propofol. All patients were ventilated via an endotracheal tube with air, oxygen, and isoflurane.  Prophylactic antiemesis – ondansetron  Analegsia – Tap Block  A standard four-port technique was used  10mm at the umbilicus, 10mm epigastric and 2 X 5mm at the right iliac fossa/hypochondrium  CO 2 insufflation below 12mmHg and rate from 1-3 L/min.  At the end of procedure, an attempt was made to evacuate all CO 2

 Early mobilization was encouraged  Postoperative feeding regime from liquids to light diet for 72 hours  Pain was assessed by the Nurse and scored using the Wong and Baker FACES pain rating scale.  Patients were reviewed in the afternoon by the anesthetic team and jointly by the surgical and the nursing team and a decision was made regarding discharge  Final decision regarding discharge made jointly by the patients’ families and the nursing team.

Normal temperature, pulse and blood pressure, Tolerance of fluid and light diet, Adequate pain control, comfortable mobilization, and patient/carer satisfaction with discharge.

 Jan 2013-July 2013 = 11 patients  M:F = 4:7  Age = years (11.8 years)  Indications for surgery – Persisting pain abdomen  Co-morbid conditions – Obesity in 2 children  Ultrasound: Done preoperatively to diagnose cholelithisis in all patients

Duration of Surgery min (Avg 57 min) Intra operative problems - Nil Post operative problems - Nil Conversion to open - Nil Pain score at Discharge – 3/10 PONV - Tolerable Pain score on follow up – 2/10 (R shoulder tip pain =4)

Admission on the day before the procedure was unnecessary Explanation of the procedure and discharge policy to the families in the outpatient setting was extremely important in acceptance of having a major procedure performed in an ambulatory setting, The use of Transversus abdominis plane (TAP) block is the cornerstone if success behind DCLC.

 Should not be underestimated.  Requires a major shift away from a traditional conservative approach with regard to introduction of enteral feeds, mobilization, and pain management.  Introduce an element of balance to the decision regarding patient discharge

Rigorous patient selection is a prerequisite for the success of DCLC. A cornerstone of successful DCLC practice is adequate pain management. The use of transversus abdominis plane block demonstrated huge benefits. No PONV due to routine combination intraoperative antiemetics, minimization of the use of long acting intravenous opioids, and a strict dietary regime

DCLC in children is feasible in the majority of patients requiring cholecystectomy as a sole procedure Performed with excellent results without compromising patient safety. A multidisciplinary team approach Adoption of a clinical care pathway Adequate pain management and avoidance of PONV are a prerequisite for success.