Significant advances in surgical techniques such as minimally invasive surgery, with the first publication of a laparoscopic cholecystectomy by F. Dubois in 1990[1], and new anesthesia protocols have enabled the development of ambulatory surgery [2]. In recent years, additional techniques have been developed with the aim of improving the performance of laparoscopy. This has taken many forms, including smaller and fewer incisions and instruments introduced through a single mini-incision, a natural orifice, or via robotic surgery [3]. The rise of ambulatory surgery is the result of improvements in anesthesia and analgesia techniques (short half-life medications), the development of ultrasound-guided regional anesthesia, and minimally invasive surgery.

Ambulatory surgery is not a new concept [4]. As early as 1909, James Nicoll in Glasgow reported a series of 7000 children operated on without hospitalization, highlighting all the advantages currently described (Cost, quality, avoidance of hospitalization). It wasn't until the 1970s that the concept resurfaced, particularly in Anglo-Saxon countries, with significant development occurring in the early 1990s (60% of procedures recorded in 1995 in the United States) [5] In California in 1962, Dillon JB and Cohen DD established the first independent ambulatory center, followed by Levy ML and Coakley CS in Washington in 1966, and subsequently in Providence (Rhode Island) in 1968 and Phoenix (Arizona) in 1970. By 1992, there were 1700 independent ambulatory surgery centers in the United States [6] In Great Britain, ambulatory surgery began to develop in the 1970s, encouraged by government authorities due to bed shortages and waiting times. In 1985, the "Guidelines of Royal College of Surgeons for Day Case Surgery" were published. In France, orthopedic surgeon Guy Foucher established the first independent ambulatory surgery center in Strasbourg in 1980, but it wasn't until the July 1991 law on hospital reform and the implementing decree no. 92-1102 of October 2, 1992, that it began to develop and find its legal framework [7]. Since then, ambulatory surgery has experienced considerable growth, particularly in Anglo-Saxon and European countries. Laparoscopic cholecystectomy as an outpatient procedure is common in the USA and Europe (33% in the UK in 2012 out of 50,000 annual cases). In France, in 2007, out of over 100,000 cholecystectomies performed, only 0.4% were done on an outpatient basis (stay of less than 12 hours), increasing to 1% in 2009 and 9% in 2012 according to ATIH (Technical Agency for Hospital Information) [8]. Ambulatory surgery: the example of laparoscopic cholecystectomy, reporting the experience of our department in this work.

A prospective, monocentric, descriptive study conducted between April 2017 and December 2018 involving 128 laparoscopic cholecystectomies performed in the Department of General Surgery at the Regional University Military Hospital of Constantine as outpatient procedures for patients meeting the following criteria: scheduled surgery, absence of major medical history, classified as ASA 1 or 2, residing within one hour of the hospital. After laparoscopic cholecystectomy, patients were discharged from the hospital in the afternoon if their condition permitted.

Anesthetic Protocol

The anesthetic protocol itself involved, at induction, 0.04 to 0.05 mg/kg of Midazolam, 1 mg of Alfentanil, 2.5 mg/kg of Propofol, 0.15 to 0.20 mg of Mivacurium. Maintenance was provided by Sevoflurane with an oxygen-nitrous oxide mixture at 50%. Alfentanil was re-administered in a bolus of 0.5 mg every 15 to 20 minutes. Mivacurium was re-administered in a bolus as needed. All patients received after intubation either an NSAID or dexamethasone 10 mg with omeprazole 40 mg, and at the end of the procedure, they were administered 1 g of paracetamol and 10 mg of metoclopramide.

Surgical Protocol

Laparoscopic cholecystectomy was performed in a standardized manner, utilizing 4 trocars and insufflation of carbon dioxide at a stable pressure of 12 mmHg with a flow rate not exceeding 1.5 mmHg/min. All procedures were conducted by a senior surgeon. Intraoperative cholangiography was not systematically performed but rather in the presence of symptoms or clinical signs, abnormalities in liver function tests, and/or dilatation of the bile ducts on ultrasound.

Postoperative Monitoring

The nurse in the outpatient unit was responsible for monitoring hemodynamic parameters, assisting with the first mobilization, initiating liquid intake (which was allowed three hours after the procedure), and facilitating patient ambulation. All patients were reviewed by the surgeon and the anesthesiologist in the afternoon. Their discharge from the hospital was authorized based on a PAADS score ≥ 9 (see annex 1).

Among the 128 patients, there were 113 (88%) females and 15 males, with a sex ratio of 0.13. The mean age was 41 years with a range of 18 to 75 years. The mean BMI was 28.49 ± 4.12 kg/m² with a range of 19.53 to 39 kg/m². All of our patients resided within an hour radius of the hospital. The average travel time was 20 minutes with a range of 10 minutes to one hour. ASA classification revealed: 96 patients as ASA 1 and 32 patients as ASA 2. The majority of patients (92.1%) presented with symptomatic but uncomplicated gallstones. Other patients presented with remote surgery for cooled cholecystitis (4.7%), post-biliary pancreatitis cholecystectomy (2.4%), and post-ERCP cholecystectomy for LVBP (0.8%). Regarding operative data, the average operative time was 67.51 minutes (range: 36 - 153 minutes). The average duration of general anesthesia was 94.42 minutes (range: 56 - 180 minutes). The average length of hospital stay was 6 hours (range: 5 - 8 hours). One hundred seventeen patients (91.41%) were discharged from the hospital on the same day of the operation. Extended stays were necessary for eleven patients, eight of whom were due to intraoperative findings: five for acute cholecystitis with dissection difficulties and three for pyocholecystitis (one of which had a postoperative tracheal rupture), one due to postoperative medical complication (coughing fits), and two for social reasons (Table 1) No patient required a second surgical intervention. Two patients contacted their general practitioner on the evening of the operation after returning home; one for postoperative vomiting and the other for medically treated scapular pain at home. Four patients were seen in consultation before the scheduled follow-up appointment for minor issues such as abdominal pain; one on postoperative day 2 for epigastric hyperalgesic crises with vomiting (abdominopelvic ultrasound and lipase levels were performed, showing no abnormalities, and the pain subsided after prescribing omeprazole), two patients for renal colic, and one patient for right-sided lower back pain, all of whom were treated solely in consultation. No patient required rehospitalization.

Table 1: Causes of cancellation of ambulatory laparoscopic cholecystectomy.

The majority of patients in our series were female, comprising 113 (88%) compared to 15 (12%) males, with a sex ratio of 0.13, indicating a specific frequency of gallstone-related pathology. The age range in our series varied between 18 and 75 years with a mean age of 41 years, as reported in a study published in 2002 by H. Johanet et al [9] (Table2). Age is often cited as a factor influencing outpatient care failure, which is logical as it correlates with increased incidence of comorbidities and biliary tract pathology. In our series, there is a highly significant correlation between age > 65 years and outpatient care failure (P= 0.01), consistent with results reported by Vandenbroucke [10] and Zaafouri. [11] In our series, patients had a low anesthetic risk, with 96 (75%) classified as ASA I and 32 (25%) as ASA II, comparable to published studies. Vandenbroucke's study included 151 patients, with 79 classifieds as ASA I, 65 as ASA II, and 7 as ASA III, concluding that ASA stage was not statistically associated with the risk of hospitalization after LCOP (P= 0.52). Zaafouri [11] similarly found that ASA II classification was not identified as a risk factor for failed outpatient care (P=0.4).

Table 2: Characteristics of the general population and ambulatory management.

Surgery Schedule

All our patients were admitted early in the day between 08:00 and 10:30, and no patient was kept overnight due to a late start of the procedure. The start time of the surgery did not influence the success of ambulatory care (P=0.04). According to Proske [17] and Vandenbroucke [10] the risk of cancellation of ambulatory procedures increases from 11 am onwards, with the failure rate rising from 11% to 54% [10,17]. Most authors set the threshold from 2 pm onwards: Akoh [18], Robinson [19] Planells Roig [20], and Teixeira [21] found that failure rates increased from 26%, 14%, and 31% before 2 pm to 51%, 62%, and 68% respectively after 2 pm (1921).

Operative and General Anesthesia Duration

Effective management of operative time is crucial for better surgical technique mastery, minimizing complications and incidents by the surgeon and their team. During our study, we observed that the duration of the procedure was prolonged due to intraoperative incidents such as gallbladder perforations, hepatic bleeding, or bleeding from the gallbladder bed. The average duration of general anesthesia was 94.42 minutes, ranging from 56 to 180 minutes, while the average duration of the surgical procedure was 67.51 minutes, ranging from 36 to 153 minutes. The duration of the surgical procedure influences outpatient care; the longer the operative time, the greater the risk of outpatient mode cancellation (P: 0.001) (Table3).

Table 3: Operating time and Ambulatory Management.

Complicated Nature of Gallbladder Lithiasis

We diagnosed acute cholecystitis intraoperatively in forty patients (31.3%), twelve cases of hydropic gallbladder (9.4%), four cases of pyocholecystitis (3.1%), and two cases of scleroatrophic gallbladders (1.6%). Outpatient cancellation was necessary for eight out of 11 patients due to intraoperative discovery of complicated gallstone disease. In our study, the complicated nature of gallbladder lithiasis has a statistically significant influence on the success of outpatient care (P: 0.004). In the study by F. Vandenbroucke et al. (10), the rate of acute cholecystitis was 7.3% of patients at the time of the intervention. This figure may be explained by underestimation of symptoms but also by the surgeon's decision to attempt the intervention nonetheless in an outpatient setting.

Causes of Prolonged Hospital Stay

In our series, among the 128 outpatient patients, 117 returned homes on the evening of the operation, while 11 remained in conventional hospital accommodation. The number of postoperative nights in conventional hospital accommodation after outpatient failure varied significantly from one night for ten patients to seven nights for one patient who experienced tracheal rupture. None of the 117 outpatient patients included in our series required further hospitalization for complications, and none died. (Table4) In the 39 studies analyzed(6), among the 81 (13.8%) patients kept overnight, 25 underwent reoperation (4.5%): 8 reinterventions for bleeding, 7 for bile leaks or bile duct injury, 3 for obstructions, 4 for subhepatic collections, and 56 underwent endoscopic sphincterotomy for LVBP 17.1% of outpatient-treated patients were readmitted, with 38.1% undergoing reoperation for 32 bile leaks or bile duct injuries, 20 subhepatic collections, 3 obstructions, one umbilical hernia repair, one hepatectomy for cancer, one duodenal perforation, one cellulitis, one cystic artery bleeding, and 54 ERCP procedures. In our study, the complicated nature of gallbladder lithiasis has a statistically significant influence on the success of outpatient care (P: 0.004).

Table 4: Reasons for cancellation of ambulatory care.

Laparoscopic cholecystectomy is highly suitable as an outpatient procedure due to its high same day discharge rate and high patient satisfaction, coupled with low readmission and complication rates. In our study involving 128 laparoscopic cholecystectomies performed on an outpatient basis, the success rate of outpatient management was 91.4%, with an overall satisfaction rate of 99%, of which 94.9% were highly satisfied. This was associated with low rates of unplanned consultations and postoperative complications, and no readmissions. It has become our standard approach for all scheduled elective cholecystectomies, with traditional hospitalization being only a rare alternative.

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